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.

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.

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

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

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.

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.

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 resection of pancreatic adenocarcinoma: Dream or reality?

Laparoscopic pancreatic surgery is in its infancy despite initial procedures reported two decades ago. Both laparoscopic distal pancreatectomy(LDP) and laparoscopic pancreaticoduodenectomy(LPD) can be performed competently; however when minimally invasive surgical(MIS) approaches are implemented the indication is often benign or low-grade malignant pathologies. Nonetheless, LDP and LPD afford improved perioperative outcomes, similar to those observed when MIS is utilized for other purposes. This includes decreased blood loss, shorter length of hospital stay, reduced post-operative pain, and expedited time to functional recovery. What then is its role for resection of pancreatic adenocarcinoma? The biology of this aggressive cancer and the inherent challenge of pancreatic surgery have slowed MIS progress in this field. In general, the overall quality of evidence is low with a lack of randomized control trials, a preponderance of uncontrolled series, short follow-up intervals, and small sample sizes in the studies available. Available evidence compiles heterogeneous pathologic diagnoses and is limited by case-by-case follow-up, which makes extrapolation of results difficult. Nonetheless, shortterm surrogate markers of oncologic success, such as margin status and lymph node harvest, are comparable to open procedures. Unfortunately disease recurrence and long-term survival data are lacking. In this review we explore the evidence available regarding laparoscopic resection of pancreatic adenocarcinoma, a promising approach for future widespread application.

National trends in resection of the distal pancreas

AIM:To investigate national trends in distal pancreatectomy(DP) through query of three national patient care databases.METHODS:From the Nationwide Inpatient Sample(NIS,2003-2009),the National Surgical Quality Improvement Project(NSQIP,2005-2010),and the Surveillance Epidemiology and End Results(SEER,2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy.Utilization of laparoscopy was defined in NIS by the International Classification of Diseases,Ninth Revision correspondent procedure code;and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes.In SEER,patients were identified by the International Classification of Diseases for Oncology,Third Edition diagnosis codes and the SEER Program Code Manual,third edition procedure codes.We analyzed the databases with respect to trends of inpatient outcome metrics,oncologic outcomes,and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection.RESULTS:NIS,NSQIP and SEER identified 4242,2681 and 11 082 DP resections,respectively.Overall,laparoscopy was utilized in 15%(NIS) and 27%(NSQIP).No significant increase was seen over the course of the study.Resection was performed for malignancy in 59%(NIS) and 66%(NSQIP).Neither patient Body mass index nor comorbidities were associated with operative approach(P = 0.95 and P = 0.96,respectively).Mortality(3% vs 2%,P = 0.05) and reoperation(4% vs 4%,P = 1.0) was not different between laparoscopy and open groups.Overall complications(10% vs 15%,P < 0.001),hospital costs [44 741 dollars,interquartile range(IQR) 28 347-74 114 dollars vs 49 792 dollars,IQR 13 299-73 463,P = 0.02] and hospital length of stay(7 d,IQR 4-11 d vs 7 d,IQR 6-10,P < 0.001) were less when laparoscopy was utilized.One and two year survival after resection for malignancy were unchanged over the course of the study(ductal adenocarinoma 1-year 63.6% and 2-year 35.1%,P = 0.53;intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%,P = 0.25).The majority of resections were performed in teaching hospitals(77% NIS and 85% NSQIP),but minimally invasive surgery(MIS) was not more likely to be used in teaching hospitals(15% vs 14%,P = 0.26).Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles(88% vs 43%,P < 0.001),but were no more likely to utilize MIS at resection.Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching(15% vs 14%,P = 0.72) and lower volume hospitals(14% vs 15%,P = 0.99).No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year(P = 0.17 and P = 0.96,respectively).CONCLUSION:There appears to be an overall underutilization of laparoscopy for DP.Centralization does not appear to be occurring.Survival and lymph node harvest have not changed.

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.

Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma:a single-center experience

Objective：The aim of this study was to compare complications and oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy（LDP）and open distal pancreatectomy（ODP）at a single center.Methods：Distal pancreatectomies performed for pancreatic ductal adenocarcinoma during a 4-year period were included in this study.A retrospective analysis of a database of this cohort was conducted.Results：Twenty-two patients underwent LDP for pancreatic ductal adenocarcinoma,in comparison to seventy-six patients with comparable tumor characteristics treated by ODP.No patients with locally advanced lesions were included in this study.Comparing LDP group to ODP group,there were no significant differences in operation time（P=0.06）or blood loss（P=0.24）.Complications（pancreatic fistula,P=0.62;intra-abdominal abscess,P=0.44;postpancreatectomy hemorrhage,P=0.34）were similar.There were no significant differences in the number of lymph nodes harvested（11.2±4.6 in LDP group vs.14.4±5.5 in ODP group,P=0.44）nor the rate of patients with positive lymph nodes（36%in LDP group vs.41%in ODP group,P=0.71）.Incidence of positive margins was similar（9%in LDP group vs.13%in ODP group,P=0.61）.The mean overall survival time was（29.6±3.7）months for the LDP group and（27.6±2.1）months for ODP group.There was no difference in overall survival between the two groups（P=0.34）.Conclusions：LDP is a safe and effective treatment for selected patients with pancreatic ductal adenocarcinoma.A slow-compression of pancreas tissue with the GIA stapler is effective in preventing postoperative pancreatic fistula.The oncologic outcome is comparable with the conventional open approach.Laparoscopic radical antegrade modular pancreatosplenectomy contributed to oncological clearance.