Robotic versus laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: A propensity score-matched analysis

Background: Minimally invasive surgery is becoming increasingly popular in the field of pancreatic surgery. However, there are few studies of robotic distal pancreatectomy(RDP) for pancreatic ductal adenocarcinoma(PDAC). This study aimed to investigate the efficacy and feasibility of RDP for PDAC. Methods: Patients who underwent RDP or laparoscopic distal pancreatectomy(LDP) for PDAC between January 2015 and September 2020 were reviewed. Propensity score matching analyses were performed. Results: Of the 335 patients included in the study, 24 underwent RDP and 311 underwent LDP. A total of 21 RDP patients were matched 1:1 with LDP patients. RDP was associated with longer operative time(209.7 vs. 163.2 min;P = 0.003), lower open conversion rate(0% vs. 4.8%;P < 0.001), higher cost(15 722 vs. 12 699 dollars;P = 0.003), and a higher rate of achievement of an R0 resection margin(90.5% vs. 61.9%;P = 0.042). However, postoperative pancreatic fistula grade B or C showed no significant intergroup difference(9.5% vs. 9.5%). The median disease-free survival(34.5 vs. 17.3 months;P = 0.588) and overall survival(37.7 vs. 21.9 months;P = 0.171) were comparable between the groups. Conclusions: RDP is associated with longer operative time, a higher cost of surgery, and a higher likelihood of achieving R0 margins than LDP.

Spleen-preserving distal pancreatectomy from multi-port to reducedport surgery approach

BACKGROUND Minimally invasive pancreatic surgery via the multi-port approach has become a primary surgical method for distal pancreatectomy(DP)due to its advantages of lower wound pain and superior cosmetic results.Some studies have applied reduced-port techniques for DP in an attempt to enhance cosmetic outcomes due to the minimally invasive effects.Numerous recent review studies have compared multi-port laparoscopic DP(LDP)and multi-port robotic DP(RDP);most of these studies concluded multi-port RDP is more beneficial than multi-port LDP for spleen preservation.However,there have been no comprehensive reviews of the value of reduced-port LDP and reduced-port RDP.AIM To search for and review the studies on spleen preservation and the clinical outcomes of minimally invasive DP that compared reduced-port DP surgery with multi-port DP surgery.METHODS The PubMed medical database was searched for articles published between 2013 and 2022.The search terms were implemented using the following Boolean search algorithm:(“distal pancreatectomy”OR“left pancreatectomy”OR“peripheral pancreatic resection”)AND(“reduced-port”OR“single-site”OR“single-port”OR“dual-incision”OR“single-incision”)AND(“spleen-preserving”OR“spleen preservation”OR“splenic preservation”).A literature review was conducted to identify studies that compared the perioperative outcomes of reduced-port LDP and reduced-port RDP.RESULTS Fifteen articles published in the period from 2013 to 2022 were retrieved using three groups of search terms.Two studies were added after manually searching the related papers.Finally,10 papers were selected after removing case reports(n=3),non-English language papers(n=1),technique papers(n=1),reviews(n=1),and animal studies(n=1).The common items were defined as items reported in more than five papers,and data on these common items were extracted from all papers.The ten studies included a total of 337 patients(females/males:231/106)who underwent DP.In total,166 patients(females/males,106/60)received multi-port LDP,126(females/males,90/36)received reduced-port LDP,and 45(females/males,35/10)received reduced-port RDP.CONCLUSION Reduced-port RDP leads to a lower intraoperative blood loss,a lower postoperative pancreatic fistula rate,and shorter hospital stay and follow-up duration,but has a lower spleen preservation rate.

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

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

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

BACKGROUND: Castleman disease is an uncommon lympho-proliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature. METHOD: This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection. RESULTS: A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease. CONCLUSIONS: Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Minimally invasive spleen-preserving distal pancreatectomy: Does splenic vessel preservation have better postoperative outcomes? A systematic review and meta-analysis

BACKGROUND： Minimally invasive spleen-preserving distal pancreatectomy （SPDP） can be performed with either splenic vessel preservation （SVP） or resection [Warshaw procedure （WP）]. The aim of this study was to evaluate the postoperative clinical outcomes of patients undergoing both methods. DATA SOURCES： Database search of PubMed, Embase, Scopus, Cochrane, and Google Scholar was performed （2000-2014）; key bibliographies were reviewed. Qualified studies compar- ing patients undergoing SPDP with either SVP or WP, and as- sessing postoperative complications were included. Calculated pooled risk ratio （RR） with the corresponding 95% confidence interval （CI） by random effects methods were used in the meta-analyses. RESULTS： The search yielded 215 studies, of which only 14 observational studies met our selection criteria. The studies included 943 patients in total; 652 （69%） underwent SVP and 291 （31%） underwent WP. Overall, there was a lower incidence of splenic infarction （RR=0.17; 95% Ch 0.09-0.33; P〈0.001）, gastric varices （RR=0.16; 95% Ch 0.05-0.51; P=0.002）, and intra/postoperative splenectomy （RR=0.20; 95% Ch 0.08-0.49; P〈0.001） in the SVP group. There was no difference in in- cidence of pancreatic fistula （WP vs SVP, 23.6% vs 22.9%;P=0.37）, length of hospital stay, operative time or blood loss. There was moderate cross-study heterogeneity. CONCLUSIONS： SVP is a safe, efficient and feasible technique that may be used to preserve the spleen. WP may be more suit- able for large tumors dose to the splenic hilum or those associ- ated with splenomegaly. Randomized clinical trials are justified to examine the long-term benefits of SVP-SPDP.

Application of retrograde distal pancreatectomy

BACKGROUND: Since conventional methods are difficult to deal with pancreatic tumors close to the portal veins, we investigated the feasibility and norms for retrograde distal pancreatectomy by cutting the neck of the pancreas first. METHOD: The clinical data and surgical procedures of retrograde distal pancreatectomy given to 11 patients from July 2001 to June 2007 were analyzed. RESULTS: All 11 operations were completed successfully. The mean time of the operation was 143 71 minutes. The mean volume of hemorrhage was 239 ml. The mean time of hospitalization was 12 +/- 4.2 days. No blood transfusion was needed during the operation, and all patients had a good postoperative recovery. No neopathy of diabetes mellitus, pancreatic fistula or other complications occurred after the operation. The follow-up of all patients (4-60 months) showed that 3 patients survived for 14, 16 and 33 months, respectively, and the other patients are still alive. CONCLUSIONS: Retrograde distal pancreatectomy is useful for exposing the portal and superior mesenteric veins while avoiding operative injury. Interception of the blood supply of the spleen helps to reduce the volume of hemorrhage, while making the operation easier and the operative time short. It is advantageous for tumor resection of the body of the pancreas near the portal veins.

Ligamentum teres hepatis patch enhances the healing of pancreatic fistula after distal pancreatectomy

Pancreatic fistula is one of the most common complications after the distal pancreatectomy.Many methods have been tried to solve the problem,but no one is optimal,especially for the soft pancreatic stump cases.This study used ligamentum teres hepatis as a patch to cover the pancreatic stump.Between October 2010 and December 2012,seventyseven patients who had undergone distal pancreatectomy with a soft pancreatic stump were divided into two groups:group A(n=39,patients received conventional ligated main pancreatic duct method)and group B(n=38,patients underwent a coverage procedure).Patients in group A had a longer recovery from postoperative pancreatic fistula than those in group B(16.4±3.5 vs 10.8±1.6 days,P【0.05).The coverage procedure with ligamentum teres hepatis is a safe,effective and convenient method for patients with a soft pancreas remnant during distal pancreatectomy.

Successful treatment of pancreatic accessory splenic hamartoma by laparoscopic spleen-preserving distal pancreatectomy:A case report

BACKGROUND Pancreatic accessory spleen(PAS)is an uncommon congenital abnormality of the spleen.Spleen hamartoma(SH)is also rare.Moreover,hamartoma in the PAS has not been reported thus far.We report the first case here.CASE SUMMARY A 26-year-old male presented with a one-month history of left upper quadrant abdominal pain,and computerized tomography(CT)examination suggested a mass in the pancreas tail.The patient then attended our hospital for diagnosis and treatment.Ultrasonography,CT,and magnetic resonance imaging revealed a solid mass with cystic degeneration growing from the tail of the pancreas.The tumor marker carbohydrate antigen 19-9(CA19-9)increased to 96.7 U/mL(normal range 0-37 U/mL).An epidermoid cyst in a PAS was considered preoperatively.However,a malignant tumor cannot be ruled out.We performed laparoscopic surgery,and two pancreatic masses were found growing from the pancreatic tail.The two masses were so closely connected that preoperative imaging examinations suggested only one mass.We carefully isolated the masses from the splenic artery and vein.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.On pathological examination,the masses were well-defined,homogeneous red-tan,4×3,and 4.5×1.5 in size,respectively.One of them was cystically degenerated.On microscopical examination,the mass contained unorganized small slit-like vascular channels enclosing red blood cells and lined with plump endothelial cells.No area of cytologic atypia was identified.Focal lymphoid aggregates were found in the intravascular areas.White pulp or fibrosis was not observed.The final diagnosis was pancreatic accessory SH with cystic degeneration.After the operation,CA19-9 was reduced to normal.The patient recovered well,and the 34-mo follow-up period was uneventful.CONCLUSION Here,we report the first case of pancreatic accessory SH.A laparoscopic spleen-preserving distal pancreatectomy was successfully performed.The patient recovered well and had a good prognosis.

Laparoscopic distal pancreatectomy in Italy:a systematic review and meta-analysis

BACKGROUND： The use of laparoscopic distal pancreatectomy（LDP） increased in the past twenty years but the real diffusion of this technique is still unknown as well as the type of centers（high or low volume） in which this procedure is more frequently performed.DATA SOURCE： A systematic review was performed to evaluate the frequency of LDP in Italy and to compare indications and results in high volume centers（HVCs） and in low volume centers（LVCs）.RESULTS： From 95 potentially relevant citations identified, only5 studies were included. A total of 125 subjects were analyzed, of whom 95（76.0%） were from HVCs and 30（24.0%） from LVCs.The mean number of LDPs performed per year was 6.5. The mean number of patients who underwent LDP per year was 8.8in HVCs and 3.0 in LVCs（P0.001）. The most frequent lesions operated on in HVCs were cystic tumors（62.1%, P0.001） while,in LVCs, solid neoplasms（76.7%, P0.001）. In HVCs, malignant neoplasms were treated with LDP less frequently than in LVCs（17.9% vs 50.0%, P〈0.001）. Splenectomy was performed for non-oncologic reason frequenter in HVCs than in LVCs（70.2%vs 25.0%, P0.004）. The length of stay was shorter in HVCs than in LVCs（7.5 vs 11.3, P0.001）. No differences were found regarding age, gender, ductal adenocarcinoma treated, operative time, conversion, morbidity, postoperative pancreatic fistula,reoperation and margin status.CONCLUSIONS： LDPs were frequently performed in Italy.The ＂HVC approach＂ is characterized by a careful selection of patients undergoing LDP. The ＂LVC approach＂ is based on the hypothesis that LDPs are equivalent both in short-term and long-term results to laparotomic approach. These data are not conclusive and they point out the need for a national register of laparoscopic pancreatectomy.

Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy:Optimal treatment of benign and malignant disease of the left pancreas

Background:Laparoscopic distal pancreatectomy(LDP)has become the preferred approach for surgical management of left sided pancreas pathology.Our institution previously published its experience with distal pancreatectomies using a clockwise technique with good outcomes.We now reexamine our outcomes across a longer time interval.Methods:From August 2008 to November 2020,364 patients underwent LDP by hepatobiliary surgeons(HA and JS).All procedures were performed using the same clockwise approach,which includes the stepwise slow compression technique.Retrospective descriptive analysis of patient demographic,clinical,operative,and pathologic data was conducted.Results:Of the 364 patients who underwent LDP using this technique,clinically significant postoperative pancreatic fistula(POPF)was noted in 26(7.1%)patients,while major morbidity and mortality were reported in 9.9%and 0.3%,respectively.Hand-assisted method was required for 18(4.9%)patients and unplanned conversion in 20(5.5%)patients.In a subset analysis of patients with pancreatic adenocarcinoma(n¼90),POPF was noted in 13(14.4%),with minor complications occurring in 34.4%and major morbidity in 14.4%.Conclusion:LDP with a clockwise approach for dissection,combined with the stepwise slow compression technique results in excellent outcomes,with even lower POPF rates than originally reported.Subset analysis of patients with pancreatic adenocarcinoma shows acceptable perioperative outcomes with this technique.

A novel clinical model for risk prediction and stratification of new-onset diabetes mellitus after distal pancreatectomy

Background:The incidence of new-onset diabetes mellitus(NODM)after distal pancreatectomy(DP)remains high.Few studies have focused on NODM in patients with pancreatic benign or low-grade malignant lesions(PBLML).This study aimed to develop and validate an effective clinical model for risk prediction and stratification of NODM after DP in patients with PBLML.Methods:A follow-up survey was conducted to investigate NODM in patients without preoperative DM who underwent DP.Four hundred and forty-eight patients from Peking Union Medical College Hospital(PUMCH)and 178 from Guangdong Provincial People’s Hospital(GDPH)met the inclusion criteria.They constituted the training cohort and the validation cohort,respectively.Univariate and multivariate Cox regression,as well as least absolute shrinkage and selection operator(LASSO)analyses,were used to identify the independent risk factors.The nomogram was constructed and verified.Concordance index(C-index),receiver operating characteristic(ROC)curve,calibration curves,and decision curve analysis(DCA)were applied to assess its predictive performance and clinical utility.Accordingly,the optimal cut-off point was determined by maximally selected rank statistics method,and the cumulative risk curves for the high-and low-risk populations were plotted to evaluate the discrimination ability of the nomogram.Results:The median follow-up duration was 42.8 months in the PUMCH cohort and 42.9 months in the GDPH cohort.The postoperative cumulative 5-year incidences of DM were 29.1%and 22.1%,respectively.Age,body mass index(BMI),length of pancreatic resection,intraoperative blood loss,and concomitant splenectomy were significant risk factors.The nomogram demonstrated significant predictive utility for post-pancreatectomy DM.The C-indexes of the nomogram were 0.739 and 0.719 in the training and validation cohorts,respectively.ROC curves demonstrated the predictive accuracy of the nomogram,and the calibration curves revealed that prediction results were in general agreement with the actual results.The considerable clinical applicability of the nomogram was certified by DCA.The optimal cut-off point for Background:The incidence of new-onset diabetes mellitus(NODM)after distal pancreatectomy(DP)remains high.Few studies have focused on NODM in patients with pancreatic benign or low-grade malignant lesions(PBLML).This study aimed to develop and validate an effective clinical model for risk prediction and stratification of NODM after DP in patients with PBLML.Methods:A follow-up survey was conducted to investigate NODM in patients without preoperative DM who underwent DP.Four hundred and forty-eight patients from Peking Union Medical College Hospital(PUMCH)and 178 from Guangdong Provincial People’s Hospital(GDPH)met the inclusion criteria.They constituted the training cohort and the validation cohort,respectively.Univariate and multivariate Cox regression,as well as least absolute shrinkage and selection operator(LASSO)analyses,were used to identify the independent risk factors.The nomogram was constructed and verified.Concordance index(C-index),receiver operating characteristic(ROC)curve,calibration curves,and decision curve analysis(DCA)were applied to assess its predictive performance and clinical utility.Accordingly,the optimal cut-off point was determined by maximally selected rank statistics method,and the cumulative risk curves for the high-and low-risk populations were plotted to evaluate the discrimination ability of the nomogram.Results:The median follow-up duration was 42.8 months in the PUMCH cohort and 42.9 months in the GDPH cohort.The postoperative cumulative 5-year incidences of DM were 29.1%and 22.1%,respectively.Age,body mass index(BMI),length of pancreatic resection,intraoperative blood loss,and concomitant splenectomy were significant risk factors.The nomogram demonstrated significant predictive utility for post-pancreatectomy DM.The C-indexes of the nomogram were 0.739 and 0.719 in the training and validation cohorts,respectively.ROC curves demonstrated the predictive accuracy of the nomogram,and the calibration curves revealed that prediction results were in general agreement with the actual results.The considerable clinical applicability of the nomogram was certified by DCA.The optimal cut-off point for risk prediction value was 2.88, and the cumulative risk curves of each cohort showed significant differences between the high- and low-risk groups. Conclusions: The nomogram could predict and identify the NODM risk population, and provide guidance to physicians in monitoring and controlling blood glucose levels in PBLML patients after DP.

Optimizing prediction models for pancreatic fistula after pancreatectomy:Current status and future perspectives

Postoperative pancreatic fistula(POPF)is a frequent complication after pancre-atectomy,leading to increased morbidity and mortality.Optimizing prediction models for POPF has emerged as a critical focus in surgical research.Although over sixty models following pancreaticoduodenectomy,predominantly reliant on a variety of clinical,surgical,and radiological parameters,have been documented,their predictive accuracy remains suboptimal in external validation and across diverse populations.As models after distal pancreatectomy continue to be pro-gressively reported,their external validation is eagerly anticipated.Conversely,POPF prediction after central pancreatectomy is in its nascent stage,warranting urgent need for further development and validation.The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance.Moreover,there is potential for the development of personalized prediction models based on patient-or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF.In the future,prospective multicenter studies and the integration of novel imaging technologies,such as artificial intelligence-based radiomics,may further refine predictive models.Addressing these issues is anticipated to revolutionize risk stratification,clinical decision-making,and postoperative management in patients undergoing pancre-atectomy.

Spleen-preserving distal pancreatectomy with conservation of the spleen vessels

Background Distal pancreatectomy traditionally included splenectomy; the spleen, however, is an important organ in the immunologic defense of the host and is worthy of preservation. The aim of this research was to study the feasibility,safety and clinical effects of spleen and splenic vessel-preserving distal pancreatectomy.Methods A retrospective review was performed for 26 patients undergoing distal pancreatectomy for benign or low grade malignant disease with splenectomy （n=13） or splenic preservation （n=13） at the First Hospital of Sun Yat-sen University and Guangdong General Hospital in Southern China from May 2002 to April 2009.Results All 26 pancreatectomies with splenectomy or splenic preservation were performed successfully. There was no statistically significant difference between two groups in mean operative time （（172±47） minutes vs. （157±52） minutes, P ＞0.05）, intraoperative estimated blood loss （（183±68） ml vs. （160±51） ml, P ＞0.05）, incidence of noninfectious and infection complication and mean length of postoperative hospital stay （（10.1±2.2） days vs. （12.1 ±4.6） days, P ＞0.05）. The platelet counts examined one week after operation were significantly higher in the distal pancreatectomy with splenectomy group than the other group （（37.3±12.8）×109/L vs. （54.7±13.2）×109/L, P ＜0.05）.Conclusions Spleen-preserving distal pancreatectomy appears to be a feasible and safe procedure. In selected cases of benign or low-grade malignant disease, spleen-preserving distal pancreatectomy is recommended.

Robotic distal pancreatectomy versus conventional laparoscopic distal pancreatectomy： a comparative study for short-term outcomes

Robotic system has been increasingly used in pancreatectomy. However, the effectiveness of this method remains uncertain. This study compared the surgical outcomes between robot-assisted laparoscopic distal pancreatectomy and conventional laparoscopic distal pancreatectomy. During a 15-year period, 35 patients underwent minimally invasive approach of distal pancreatectomy in our center. Seventeen of these patients had robot-assisted laparoscopic approach, and the remaining 18 had conventional laparoscopic approach. Their operative parameters and perioperative outcomes were analyzed retrospectively in a prospective database. The mean operating time in the robotic group （221.4 min） was significantly longer than that in the laparoscopic group （173.6 min） （P = 0.026）. Both robotic and conventional laparoscopic groups presented no significant difference in spleen-preservation rate （52.9% vs. 38.9%） （P = 0.505）, operative blood loss （100.3 ml vs. 268.3 ml） （P = 0.29）, overall morbidity rate （47.1% vs. 38.9%） （P = 0.73）, and post-operative hospital stay （11.4 days vs. 14.2 days） （P = 0.46）. Both groups also showed no perioperative mortality. Similar outcomes were observed in robotic distal pancreatectomy and conventional laparoscopic approach. However, robotic approach tended to have the advantages of less blood loss and shorter hospital stay. Further studies are necessary to determine the clinical position of robotic distal pancreatectomy.

Which method of distal pancreatectomy is cost-effective among open,laparoscopic,or robotic surgery?

Background: The aim of this study was to analyze the clinical and economic impact of robotic distal pancreatectomy, laparoscopic distal pancreatectomy, and open distal pancreatectomy. Methods: All consecutive patients who underwent distal pancreatic resection for benign and malignant diseases between January 2012 and December 2015 were prospectively included. Cost analysis was performed;all charges from patient admission to discharge were considered. Results: There were 21 robotic (RDP), 25 laparoscopic (LDP), and 43 open (ODP) procedures. Operative time was longer in the RDP group (RDP =345 minutes, LDP =306 min, ODP =251 min, P=0.01). Blood loss was higher in the ODP group (RDP =192 mL, LDP =356 mL, ODP =573 mL, P=0.0002). Spleen preservation was more frequent in the RDP group (RDP =66.6%, LDP =61.9%, ODP =9.3%, P=0.001). The rate of patients with Clavien-Dindo > grade III was higher in the ODP group (RDP =0%, LDP =12%, ODP =23%, P=0.01), especially for non-surgical complications, which were more frequent in the ODP group (RDP =9.5%, LDP =24%, ODP =41.8%, P=0.02). Length of hospital stay was increased in the ODP group (ODP =19 days, LDP =13 days, RDP =11 days, P=0.007). The total cost of the procedure, including the surgical procedure and postoperative course was higher in the ODP group (ODP =30,929 Euros, LDP=22,150 Euros, RDP =21,219 Euros, P=0.02). Conclusions: Cost-effective results of RDP seem to be similar to LDP with some better short-term outcomes.

Values of spleen-preserving distal pancreatectomy in well-differentiated non-functioning pancreatic neuroendocrine tumors:a comparative study

Background The feasibility of spleen-preserving distal pancreatectomy(SPDP)to treat well-differentiated non-functioning pancreatic neuroendocrine tumors(NF-pNETs)located at the body and/or tail of the pancreas remains controversial.Distal pancreatectomy with splenectomy(DPS)has been widely applied in the treatment of NF-pNETs;however,it may increase the post-operative morbidities.This study aimed to evaluate whether SPDP is inferior to DPS in post-operative outcomes and survivals when being used to treat patients with NF-pNETs in our institute.Methods Clinicopathological features of patients with NF-pNETs who underwent curative SPDP or DPS at the First Affiliated Hospital of Sun Yat-sen University(Guangzhou,China)between January 2010 and January 2022 were collected.Short-term outcomes and 5-year survivals were compared between patients undergoing SPDP and those undergoing DPS.Results Sixty-three patients(SPDP,27;DPS,36)with well-differentiated NF-pNETs were enrolled.All patients had grade 1/2 tumors.After identifying patients with T1–T2 NF-pNETs(SPDP,27;DPS,15),there was no disparity between the SPDP and DPS groups except for tumor size(median,1.4 vs 2.6 cm,P=0.001).There were no differences in operation time(median,250 vs 295 min,P=0.478),intraoperative blood loss(median,50 vs 100 mL,P=0.145),post-operative major complications(3.7%vs 13.3%,P=0.287),clinically relevant post-operative pancreatic fistula(22.2%vs 6.7%,P=0.390),or post-operative hospital stays(median,9 vs 9 days,P=0.750)between the SPDP and DPS groups.Kaplan–Meier curve showed no significant differences in the 5-year overall survival rate(100%vs 100%,log-rank P>0.999)or recurrence-free survival(100%vs 100%,log-rank P>0.999)between patients with T1–T2 NF-pNETs undergoing SPDP and those undergoing DPS.Conclusions In patients with T1–T2 well-differentiated NF-pNETs,SPDP could achieve comparable post-operative outcomes and prognosis compared with DPS.

Quality of life after pancreatic surgery

BACKGROUND Pancreatic surgery is challenging owing to the anatomical characteristics of the pancreas.Increasing attention has been paid to changes in quality of life(QOL)after pancreatic surgery.AIM To summarize and analyze current research results on QOL after pancreatic surgery.METHODS A systematic search of the literature available on PubMed and EMBASE was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Relevant studies were identified by screening the references of retrieved articles.Studies on patients’QOL after pancreatic surgery published after January 1,2012,were included.These included prospective and retrospective studies on patients'QOL after several types of pancreatic surgeries.The results of these primary studies were summarized inductively.RESULTS A total of 45 articles were included in the study,of which 13 were related to pancreaticoduodenectomy(PD),seven to duodenum-preserving pancreatic head resection(DPPHR),nine to distal pancreatectomy(DP),two to central pancre-atectomy(CP),and 14 to total pancreatectomy(TP).Some studies showed that 3-6 months were needed for QOL recovery after PD,whereas others showed that 6-12 months was more accurate.Although TP and PD had similar influences on QOL,patients needed longer to recover to preoperative or baseline levels after TP.The QOL was better after DPPHR than PD.However,the superiority of the QOL between patients who underwent CP and PD remains controversial.The decrease in exocrine and endocrine functions postoperatively was the main factor affecting the QOL.Minimally invasive surgery could improve patients’QOL in the early Core Tip:This review summarizes and analyzes current research results on quality of life(QOL)after pancreatic surgery.The article covers the discussion and analysis of the QOL of various pancreatic surgeries.Which kind of surgical procedure has better QOL is controversial.The long-term benefits on QOL of minimally invasive surgery over open surgery are contro-INTRODUCTION The pancreas,located in the retroperitoneum,is a glandular organ with endocrine and exocrine functions.It can be divided into four main parts:Head,neck,body,and tail.Pancreatic surgery can be divided into pancreaticoduoden-ectomy(PD),duodenum-preserving pancreatic head resection(DPPHR),distal pancreatectomy(DP),central pancre-atectomy(CP),and total pancreatectomy(TP).Pancreatic surgery is challenging due to the organ’s complex anatomical structure,peripheral vascularity,and intractable postoperative complications.Following the standardization of surgical steps and improvements in relevant medical techniques and surgical instruments,the safety of pancreatic surgery has significantly improved.Perioperative morbidity,mortality,and other related indicators have become more acceptable.However,owing to the organ’s essential role in digestion,absorption,and blood glucose regulation,changes in the quality of life(QOL)of patients after pancreatic surgery have attracted the attention of surgeons.More patients with non-malignant pancreatic diseases are willing to undergo surgical treatment because of the acceptable safety.In this case,from the perspective of the patient postoperatively,the significance of rehabilitation reflects the traditional perioperative outcome and QOL[1].The QOL is a new concept that extends beyond health.Although there is no consensus on its conception[2],we can consider it a multi-dimensional architecture that incorporates objective and individual subjective views of aspects of one’s physical,psychological,and social well-being[3-5].It includes evaluating physical health,and many subscales,such as emotion,job,culture,family,sociability,economy,cognition,happiness,sex,and some symptoms[6].Since people have realized the importance of QOL,many QOL scales have emerged,including the European Organization for Research and Treatment of Cancer QLQ-C30,European Quality of Life 5-dimension,36-item Short,etc.However,it is challenging to follow up on patients’QOL once they are discharged from the hospital.Consequently,most relevant studies had small sample sizes or lacked long-term follow-up results.Moreover,a summary of studies on QOL after pancreatic surgery is lacking.This study assessed the QOL in patients who underwent PD,DPPHR,DP,CP and TP.We conducted this study to describe the existing findings on the QOL after pancreatic surgery to make it easier for surgeons and patients to decide on a surgical approach.In addition,we attempted to identify controversial results to encourage further targeted research.

Central pancreatectomy for benign or low-grade malignant pancreatic tumors in the neck and body of the pancreas

BACKGROUND For tumors in the neck and body of the pancreas,distal pancreatectomy(DP)has been the standard surgical procedure for the last few decades and central pancreatectomy(CP)is an alternative surgical option.Whether CP better preserves remnant pancreatic endocrine and exocrine functions after surgery remains a subject of debate.AIM To evaluate the safety and efficacy of CP compared with DP for benign or lowgrade malignant pancreatic tumors in the neck and body of the pancreas.METHODS This retrospective study enrolled 296 patients who underwent CP or DP for benign and low-malignant neoplasms at the same hospital between January 2016 and March 2020.Perioperative outcomes and long-term morbidity of endocrine/exocrine function were prospectively evaluated.RESULTS No significant difference was observed in overall morbidity or clinically relevant postoperative pancreatic fistula between the two groups(P=0.055).Delayed gastric emptying occurred more frequently in the CP group than in the DP group(29.4%vs 15.3%;P<0.005).None of the patients in the CP group had new-onset or aggravated distal metastasis,whereas 40 patients in the DP group had endocrine function deficiency after surgery(P<0.05).There was no significant difference in the incidence of diarrhea immediately after surgery,but at postoperative 12 mo,a significantly higher number of patients had diarrhea in the DP group than in the CP group(0%vs 9.5%;P<0.05).CONCLUSION CP is a generally safe procedure and is better than DP in preserving long-term pancreatic endocrine and exocrine functions.Therefore,CP might be a better option for treating benign or low-grade malignant neoplasms in suitable patients.

Minimally invasive vs open pancreatectomy for nonfunctioning pancreatic neuroendocrine tumors

BACKGROUND The mainstay of treating nonfunctioning-pancreatic neuroendocrine tumors(NFPNETs)is surgical resection.However,minimally invasive approaches to pancreatic resection for treating NF-PNETs are not widely accepted,and the longterm oncological outcomes of such approaches remain unknown.AIM To determine the short-and long-term outcomes of minimally invasive pancreatic resection conducted in patients with NF-PNETs.METHODS Prospective databases from Severance Hospital were searched for 110 patients who underwent curative resection for NF-PNETs between January 2003 and August 2018.RESULTS The proportion of minimally invasive surgery(MIS)procedures performed for NF-PNET increased to more than 75%after 2013.There was no significant difference in post-operative complications(P=0.654),including pancreatic fistula(P=0.890)and delayed gastric emptying(P=0.652),between MIS and open approaches.No statistically significant difference was found in disease-free survival between the open approach group and the MIS group(median follow-up period,28.1 mo;P=0.428).In addition,the surgical approach(MIS vs open)was not found to be an independent prognostic factor in treating NF-PNET patients[Exp(β)=1.062;P=0.929].CONCLUSION Regardless of the type of surgery,a minimally invasive approach can be safe and feasible for select NF-PNET patients.

Pancreatic adenocarcinoma: A review of recent paradigms and advances in epidemiology, clinical diagnosis and management

Pancreatic cancer is one of the dreaded malignancies for both the patient and the clinician.The five-year survival rate of pancreatic adenocarcinoma(PDA)is as low as 2%despite multimodality treatment even in the best hands.As per the Global Cancer Observatory of the International Agency for Research in Cancer estimates of pancreatic cancer,by 2040,a 61.7%increase is expected in the total number of cases globally.With the widespread availability of next-generation sequencing,the entire genome of the tumors is being sequenced regularly,providing insight into their pathogenesis.As invasive PDA arises from pancreatic intraepithelial neoplasia and mucinous neoplasm and intraductal papillary neoplasm,screening for them can be beneficial as the disease is curable with resection at an early stage.Routine preoperative biliary drainage has no role in patients suffering from PDA with obstructive jaundice.If performed,metallic stents are preferred over plastic ones.Minimally invasive procedures are preferred to open procedures as they have less morbidity.The duct-to-mucosa technique for pancreaticojejunostomy is presently widely practiced.The role of intraperitoneal drains after surgery for PDA is controversial.Neoadjuvant chemoradiotherapy has been proven to have a significant role both in locally advanced as well as in resectable PDA.Many new regimens and drugs have been added in the arsenal of chemoradiotherapy for metastatic disease.The roles of immunotherapy and gene therapy in PDA are being investigated.This review article is intended to improve the understanding of the readers with respect to the latest updates of PDA,which may help to trigger new research ideas and make better management decisions.