Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
.pdf
Management of solid and cystic lesions of the pancreas 319
42 Regine WF, Winter KA, Abrams RA, et al. Fluorouracil vs
gemcitabine chemotherapy before and after fluorouracilbased chemoradiation following resection of pancreatic
adenocarcinoma: a randomized controlled trial. JAMA
2008; 299(9):1019–1026.
43 Ueno H, Kosuge T, Matsuyama Y, et al. A randomised phase
III trial comparing gemcitabine with surgery-only in patients
with resected pancreatic cancer: Japanese Study Group of
Adjuvant Therapy for Pancreatic Cancer. Br J Cancer 2009;
101(6):908–915.
44 Liao WC, Chien KL, Lin YL, et al. Adjuvant treatments for
resected pancreatic adenocarcinoma: a systematic review
and network meta-analysis. Lancet Oncol 2013; 14(11):
1095–1103.
45 Crane CH, Varadhachary G, Wolff RA, Pisters PW, Evans DB.
The argument for pre-operative chemoradiation for localized, radiographically resectable pancreatic cancer. Best
Pract Res Clin Gastroenterol 2006; 20(2):365–382.
46 Ishikawa O, Ohigashi H, Imaoka S, et al. Concomitant benefit
of preoperative irradiation in preventing pancreas fistula
formation after pancreatoduodenectomy. Arch Surg 1991;
126(7):885–889.
47 Cheng ZX, Wang DW, Liu T, et al. Effects of the HIF-1alpha
and NF-kappaB loop on epithelial-mesenchymal transition
and chemoresistance induced by hypoxia in pancreatic
cancer cells. Oncol Rep 2014; 31(4):1891–1898.
48 Evans DB, Varadhachary GR, Crane CH, et al. Preoperative
gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol
2008; 26(21):3496–3502.
49 Varadhachary GR, Wolff RA, Crane CH, et al. Preoperative
gemcitabine and cisplatin followed by gemcitabine-based
chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol 2008; 26(21):3487–3495.
50 Jayakrishnan TT, Nadeem H, Groeschl RT, et al. Diagnostic
laparoscopy should be performed before definitive resection
for pancreatic cancer: a financial argument. HPB 2015;
17(2):131–139.
51 AlexakisN, Gomatos IP,Sbarounis S, et al. High serumCA 19-
9 but not tumor size should select patients for staging laparoscopy in radiological resectable pancreas head and periampullary cancer. Eur J Surg Oncol 2015; 41(2):265–269.
52 Rehman S, John SK, Lochan R, et al. Oncological feasibility
of laparoscopic distal pancreatectomy for adenocarcinoma: a
single-institution comparative study. World J Surg 2014;
38(2):476–483.
53 Nilsson O, van Cutsem E, delle Fave G, et al. Poorly differ-
entiated carcinomas of the foregut (gastric, duodenal and
pancreatic). Neuroendocrinology 2006; 84(3):212–215.
Hassan MM, Phan A, Li D, Dagohoy CG, Leary C, Yao JC.
54
Family history of cancer and associated risk of developing
neuroendocrine tumors: a case–control study. Cancer Epidemiol Biomarkers Prev 2008; 17(4):959–965.
55 Zhang J, Francois R, Iyer R, Seshadri M, Zajac-Kaye M,
Hochwald SN. Current understanding of the molecular
biology of pancreatic neuroendocrine tumors. J Natl Cancer
Inst 2013; 105(14):1005–1017.
56 CapellaC,HeitzPU,Hofl er H, Solcia E, Kloppel G. Revised
classification of neuroe ndoc ri ne tumours of the
lung, pancreas and gut. Virchows Arch 1995; 425(6):
547–560.
57 Kloppel G, Heitz PU, Capella C, Solcia E. Pathology and
nomenclature of human gastrointestinal neuroendocrine
(carcinoid) tumors and related lesions. World J Surg
1996; 20(2):132– 141.
58 Rindi G, Kloppel G, Alhman H, et al. TNM staging of foregut
(neuro)endocrine tumors: a consensus proposal including a
grading system. Virchows Arch 2006; 449(4):395–401.
59 Strosberg JR, Cheema A, Weber JM, et al. Relapse-free
survival in patients with nonmetastatic, surgically resected
pancreatic neuroendocrine tumors: an analysis of the AJCC
and ENETS staging classifications. Ann Surg 2012; 256(2):
321–325.
60 McCall CM, Shi C, Cornish TC, et al. Grading of well-
differentiated pancreatic neuroendocrine tumors is
improved by the inclusion of both Ki67 proliferative index
and mitotic rate. Am J Surg Pathol 2013; 37(11):1671–1677.
61 Ellison TA, Wolfgang CL, Shi C, et al. A single institution’s
26-year experience with nonfunctional pancreatic neuroendocrine tumors: a validation of current staging systems
and a new prognostic nomogram. Ann Surg 2014; 259(2):
204–212.
62 Lewis RB, Lattin GE Jr, Paal E. Pancreatic endocrine tumors:
radiologic-clinicopathologic correlation. Radiographics
2010; 30(6):1445–1464.
63 Foti G, Boninsegna L, Falconi M, Mucelli RP. Preoperative
assessment of nonfunctioning pancreatic endocrine
tumours: role of MDCT and MRI. Radiol Med 2013; 118(7):
1082–1101.
64 Manfredi R, Bonatti M, Mantovani W, et al. Non-hyper-
functioning neuroendocrine tumours of the pancreas: MR
imaging appearance and correlation with their biological
behaviour. Eur Radiol 2013; 23(11):3029–3039.
65 Kang BK, Kim JH, Byun JH, et al. Diffusion-weighted MRI:
usefulness for differentiating intrapancreatic accessory
spleen and small hypervascular neuroendocrine tumor of
the pancreas. Acta Radiol 2014; 55(10):1157–1165.
66 Atiq M, Bhutani MS, Bektas M, et al. EUS-FNA for pancreatic
neuroendocrine tumors: a tertiary cancer center experience.
Dig Dis Sci 2012; 57(3):791–800.
Rufini V, Calcagni ML, Baum RP. Imaging of neuro-
67
endocrine tumors. Semin Nucl Med 2006; 36(3):228–247.
68 Fischer L, Kleeff J, Esposito I, et al. Clinical outcome and
long-term survival in 118 consecutive patients with neuroendocrine tumours of the pancreas. Br J Surg 2008; 95(5):
627–635.
320 Chapter 22
69 Arvold ND, Willett CG, Fernandez-del Castillo C, et al. Pan-
creatic neuroendocrine tumors with involved surgical margins: prognostic factors and the role of adjuvant
radiotherapy. Int J Radiat Oncol Biol Phys 2012; 83(3):
e337–343.
70 Zagar TM, White RR, Willett CG, et al. Resected pancreatic
neuroendocrine tumors: patterns of failure and diseaserelated outcomes with or without radiotherapy. Int J Radiat
Oncol Biol Phys 2012; 83(4):1126–1131.
71 Brenner B, Shah MA, Gonen M, Klimstra DS, Shia J, Kelsen
DP. Small-cell carcinoma of the gastrointestinal tract: a
retrospective study of 64 cases. Br J Cancer 2004; 90
(9):1720–1726.
72 StrosbergJR,CoppolaD,KlimstraDS,et al. The NANETS
consensus guidelines for the diagnosis and management
of poorly differentiated (high-grade) extrapulmonary
neuroendocrine carcinomas. Pancreas 2010; 39(6):
799–800.
73 Barber TW, Hofman MS, Thomson BN, Hicks RJ. The poten-
tial for induction peptide receptor chemoradionuclide therapy to render inoperable pancreatic and duodenal
neuroendocrine tumours resectable. Eur J Surg Oncol
2012; 38(1):64–71.
74 Sowa-Staszczak A, Pach D, Chrzan R, et al. Peptide receptor
radionuclide therapy as a potential tool for neoadjuvant
therapy in patients with inoperable neuroendocrine
tumours (NETs). Eur J Nucl Med Molec Imag 2011; 38
(9):1669–1674.
75 Ezziddin S, Lauschke H, Schaefers M, et al. Neoadjuvant
downsizing by internal radiation: a case for preoperative
peptide receptor radionuclide therapy in patients with pancreatic neuroendocrine tumors. Clin Nucl Med 2012; 37(1):
102–104.
76 Kouvaraki MA, Ajani JA, Hoff P, et al. Fluorouracil, doxo-
rubicin, and streptozocin in the treatment of patients with
locally advanced and metastatic pancreatic endocrine carcinomas. J Clin Oncol 2004; 22(23):4762–4771.
77 Devata S, Kim EJ. Neoadjuvant chemotherapy with cape-
citabine and temozolomide for unresectable pancreatic neuroendocrine tumor. Case Rep Oncol 2012; 5(3):622–626.
78 Norton JA, Kivlen M, Li M, Schneider D, Chuter T, Jensen
RT. Morbidity and mortality of aggressive resection in
patients with advanced neuroendocrine tumors. Arch
Surg 2003; 138(8):859–866.
79 Cusati D, Zhang L, Harmsen WS, et al. Metastatic nonfunc-
tioning pancreatic neuroendocrine carcinoma to liver:
surgical treatment and outcomes. J Am Coll Surg 2012;
215(1):117–124; discussion 124–125.
80 Kazanjian KK, Reber HA, Hines OJ. Resection of pancreatic
neuroendocrine tumors: results of 70 cases. Arch Surg 2006;
141(8):765–769; discussion 769–770.
81 Mortenson MM, Katz MH, Tamm EP, et al. Current diagnosis
and management of unusual pancreatic tumors. Am J Surg
2008; 196(1):100–113.
82 Laffan TA, Horton KM, Klein AP, et al. Prevalence of
unsuspected pancreatic cysts on MDCT. Am J Roentgenol
191(3):802–807.
2008;
83 De Jong K, Nio CY, Hermans JJ, et al. High prevalence of
pancreatic cysts detected by screening magnetic resonance
imaging examinations. Clin Gastroenterol Hepatol 2010;
8(9):806–811.
84 Fernandez-del Castillo C, Targarona J, Thayer SP, Rattner
DW, Brugge WR, Warshaw AL. Incidental pancreatic cysts:
clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg 2003; 138(4):427–423; discussion 433–434.
85 Tseng JF, Warshaw AL, Sahani DV, Lauwers GY, Rattner
DW, Fernandez-del Castillo C. Serous cystadenoma of the
pancreas: tumor growth rates and recommendations for
treatment. Ann Surg 2005; 242(3):413–419; discussion
419–421.
86 Klibansky D, Reid-Lombardo K, Gordon S, Gardner T. The
clinical relevance of the increasing incidence of intraductal
papillary mucinous neoplasm. Clin Gastroenterol Hepatol
2012; 10(5):555– 558.
87 Capurso G, Boccia S, Salvia R, et al. Risk factors for intra-
ductal papillary mucinous neoplasm (IPMN) of the pancreas: a multicentre case–control study. Am J Gastroenterol
2013; 108(6):1003–1009.
88 Morales-Oyarvide V, Yoon WJ, Ingkakul T, et al. Cystic
pancreatic neuroendocrine tumors: the value of cytology
in preoperative diagnosis. Cancer Cytopathol 2014; 122(6):
435–444.
89 Liu K, Peng W, Zhou Z. The CT findings of pancreatic acinar
cell carcinoma in five cases. Clin Imag 2013; 37(2):302–307.
90 Colarian J, Fowler D, Schor J, Poolos S. Squamous cell
carcinoma of the pancreas with cystic degeneration. South
Med J 2000; 93(8):821–822.
91 Scott R, Jersky J, Hariparsad G. Case report: malignant
giant cell tumour of the pancreas presenting as a
large pancreatic cyst. Br J Radiol 1993; 66(791):
1055–1057.
92 Ramirez Plaza CP, Suarez Munoz MA, Santoyo Santoyo J,
et al. [Pancreatic cystic metastasis from pulmonary carcinoma. Report of a case]. Ann Ital Chirurg 2001; 72(1):
95–99.
93 Bachmeyer C, Alovor G, Chatelain D, et al. Cystic metastasis
of the pancreas indicating relapse of Merkel cell carcinoma.
Pancreas 2002; 24(1):103–105.
94 Katz MH, Mortenson MM, Wang H, et al. Diagnosis and
management of cystic neoplasms of the pancreas: an evidence-based approach. J Am Coll Surg 2008; 207(1):
106–120.
95 Tirkes T, Aisen AM, Cramer HM, Zyromski NJ, Sandrase-
garan K, Akisik F. Cystic neoplasms of the pancreas; findings
on magnetic resonance imaging with pathological, surgical,
and clinical correlation. Abdom Imag 2014; 39(5):
1088–1101.
Management of solid and cystic lesions of the pancreas 321
96TanakaM,ChariS,AdsayV,et al.International
consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 2006; 6 (1–2):
17–32.
97 Tanaka M, Fernandez-del Castillo C, Adsay V, et al. Interna-
tional consensus guidelines 2012 for the management
of IPMN and MCN of the pancreas. Pancreatology 2012;
12(3):183–197.
98 Law JK, Hruban RH, Lennon AM. Management of pancre-
atic cysts: a multidisciplinary approach. Curr Opin Gastroenterol 2013; 29(5):509–516.
99 Enestvedt BK, Ahmad N. To cease or ‘de-cyst’? The evalua-
tion and management of pancreatic cystic lesions. Curr
Gastroenterol Rep 2013; 15(10):348.
Videos 20–26 will be of interest to readers of this chapter.
Visit the companion website at:
100 DeWitt J, McGreevy K, Schmidt CM, Brugge WR. EUS-
guided ethanol versus saline solution lavage for pancreatic
cysts: a randomized, double-blind study. Gastrointest
Endosc 2009; 70(4):710–723.
101 DeWitt J, DiMaio CJ, Brugge WR. Long-term follow-up of
pancreatic cysts that resolve radiologically after EUS-guided
ethanol ablation. Gastrointest Endosc 2010; 72(4):862–866.
102 Millikan KW, Deziel DJ, Silverstein JC, et al. Prognostic
factors associated with resectable adenocarcinoma of the
head of the pancreas. Am Surg 1999; 65: 618–624.
103 Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U,
Mosella G. Survival after pancreaticoduodenectomy for
ductal adenocarcinoma of the head of the pancreas. Chir
Ital 2000; 52: 263–270.
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
CHAPTER 23
Laparoscopic pancreatic surgery
Daniel Richard Rutz and David A. Kooby
Department of Surgery, Emory University School of Medicine, Atlanta, USA
EDITOR COMMENT
In this c hap ter, the authors summarize the results of t he most commonly performed pancr eat ic resections: enu cle ati on, distal
pancreatectomy, and pancreaticoduodenectomy. Expected outcomes and technical considerations are discussed. Based on the
presented data, distal pancreatectomy can provide comparable oncological outcomes with fewer complications, lower blood loss,
and shorter hospital stay compared with open surgery for cancers of similar complexity. Laparoscopic enucleation is less commonly
performed but has a role in the management of indolent small tumors not involving or approaching the main pancreatic duct. This
especially includes pancreatic neuroendocrine tumors. While randomized controlled prospective data comparing laparoscopic with
open pancreatic surgery are not available, the retrospective data presented by the authors are reassuring. While desirable,
prospective data are difficult to obtain because of differences in technique, application of perioperative chemotherapy and
chemoradiation, patient selection, surgeon and patient bias, and availability of experienced laparoscopic surgeons. Finally, the
authors present the available data on laparoscopic pancreaticoduodenectomy. It indicates that this procedure is still in the
developmental phase and practiced by a limited number of surgeons in selected centers. Laparoscopic pancreatic surgeons should
be very familiar with t he data presented in this chapter i n order to put their own results in to the perspective of the current ou tc om e
benchmarks for advanced laparoscopic pancreatic surger y.
Keywords: distal pancreatectomy, laparoscopic pancreas resection, pancreatic enucleation, pancreatic neoplasm,
pancreaticoduodenectomy
23.1 Introduction
Since the first laparoscopic cholecystectomy in 1985, minimally invasive techniques have been adopted for many
abdominal surgical procedures [1]. Through the use of
smaller incisions and pneumoperitoneum, the laparoscopic
approach results in improved cosmesis, reduced postoperative pain, and quicker recovery for many patients [2].
There appear to be immunological benefits associated with
minimally invasive procedures through stress reduction and
perhaps attenuation of tumor growth in the experimental
setting [3]. Because of the longer learning curves and higher
morbidity inherently associated with pancreatic surgery, the
surgical community has adopted minimally invasive
approaches to pancreatic resection more slowly than with
many other organ sites. Pancreatic resections require accessing the retroperitoneum, dissecting around delicate vascula-
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
322
ture, and manipulating a soft, sensitive organ with both
exocrine and endocrine function. With increased surgical
experience and improvements in instrumentation, laparoscopic pancreatic resections have surged at high-volume
centers for treatment of both benign and, increasingly,
malignant disease. Emerging data from various reports demonstrate that laparoscopic pancreatic resections are both safe
and effective compared with traditional open procedures.
This review will highlight existing data and recent advances
in the subject of laparoscopic pancreatic resection. Robotic
pancreatectomy will be discussed elsewhere.
23.2 Laparoscopic distal pancreatectomy
Laparoscopic distal pancreatectomy (LDP) is the most
commonly performed minimally invasive resection
Laparoscopic pancreatic surgery 323
involving the pancreas [4]. While it typically requires no
anastomosis and is usually less technically demanding
than laparoscopic pancreaticoduodenectomy, LDP still
involves complex retroperitoneal access, careful dissection, and avoidance of injury to critical surrounding
structures. The complexity of this operation varies tremendously with patient body habitus, tumor type, and
tumor location within the gland.
23.2.1 Patient selection
Laparoscopic distal pancreatectomy is appropriate for
benign and malignant pancreatic lesions located to the
left of or overlying the superior mesenteric vein (SMV) in
the pancreatic body or tail that are amenable to resection.
Ideal candidates for this approach are those patients
diagnosed with benign behaving disease requiring resection or those with pancreatic malignancies without substantial invasion of surrounding organs, major vessels
(common hepatic artery, superior mesenteric artery
[SMA], celiac axis, or portal vein) or distant metastases
(with some exceptions) [5]. See Figure 23.1.
Malignant cases requiring combined venous resection
or removal of adjacent organs such as left adrenal gland,
portion of stomach, transverse colon, and left kidney that
can result in R0 resection may be appropriate for a
laparoscopic approach [6]. With greater experience,
Figure 23.1 Axial CT scan showing pancreatic cystic tumor
with mural nodule (arrow).
surgeon selection criteria have widened to include
patients with increased comorbidities (Charlson score
>2 40.9% vs 16.7%, P = 0.003) and larger, more medial
tumors (specimen length 10.6 cm vs 8.3 cm, P < 0.001)
and more proximal tumor location (74.2% vs 26.2%,
P < 0.001) without significant increase in morbidity [7].
Careful selection of eligible patients is advised to limit the
need for conversion to open resection, as intraoperative
conversion may be associated with increased morbidity
(36% vs 20%, P = 0.008) and a higher incidence of
postoperative pancreatic fistula (POPF) (27% vs 13%,
P = 0.03) compared with performing the case open from
the start [8]. Patients undergoing planned splenectomy
should be immunized against encapsulated bacterial
organisms 14 days prior to surgery. If this is not possible,
immunizations can be given after postoperative day 14 as
opsonophagocytic function of antibodies is enhanced
after this time [9].
23.2.2 Technical considerations
Common variations of LDP technique include LDP with
splenectomy, spleen-preserving LDP, and radical antegrade modular pancreatectomy. Technical details of each
can be found elsewhere in the literature [5,10–13].
Briefly, depending on the indication, the patient is positioned either supine or in a “lazy” right-lateral decubitus
position (authors’ preferred approach), and the abdomen
is entered with 3–5 ports placed in various positions in the
mid-left abdomen (Figure 23.2).
The peritoneal cavity is assessed for possible metastases.
The stomach is retracted cephalad or towards the right
and the splenic flexure of the colon is dropped, and the
pancreas thus exposed and assessed with ultrasonography if necessary. The gland is mobilized from medial to
lateral or vice versa, and the splenic vasculature is divided
with surgical staplers (or preserved if desired and appropriate), followed by gland transection in the appropriate
location. If the spleen is to be removed, it is mobilized and
placed in a sac for subsequent removal en bloc or morselized separately.
Splenic conservation, when possible, may provide
long-term immunological benefit for the patient. This is
accomplished in two ways. The Warshaw technique
involves ligating and dividing the splenic vessels at the
pancreatic neck and near the splenic pedicle and removing them with the distal pancreas, leaving short gastric
and left gastroepiploic vessels to perfuse the spleen [14].
While easier to perform, this technique compromises
324 Chapter 23
Figure 23.2 Laparoscopic distal pancreatectomy port sites. Right panel demonstrates the schematic port placement and left panel
shows a patient 3 weeks after distal pancreatectomy for an 8 cm neuroendocrine tumor of the pancreatic body with splenic vein
obstruction and bleeding gastric varices.
blood flow to the spleen and has been associated with
splenic infarction and abscess [15]. The other method of
splenic preservation involves careful dissection of the pancreatic tail away from the splenic vessels and preservation
of the splenic artery and vein (Kimura method). This
technique is ideal for asthenic patients with nonmalignant
tumors and accessible vessels, as there is wide anatomical
variability. A recent comparative analysis of LDP and these
two approaches to splenic preservation demonstrated that
the rate of successful spleen preservation was significantly
improved following the splenic vessel preservation technique (96.4% vs 84.7%, P = 0.03) [16].
Splenic preservation at the time of operation is influenced by tumor biology and surgeon preference. The
magnification afforded by the laparoscopic approach
can improve visualization of the resection bed, leading
to a higher rate of splenic preservation [17]. Butturini
et al. compared results of 116 DPs, of which 43 were
performed laparoscopically. They demonstrated a higher
incidence of splenic preservation in the laparoscopic
group (44.2% vs 11%, P < 0.001) with comparable rates
of morbidity (48.2% vs 45.2%, P = 0.71) [18]. Song et al.
looked at perioperative outcomes in 359 LDP cases, 90%
of which were benign resections. Splenic preservation
was successful 49.6% of the time and the overall complication rate was 12% [17]. In a retrospective analysis of
360 DPs that included 71 LDPs, DiNorcia et al. showed
similar rates of postoperative morbidity (43.9% vs 39%,
P = 0.56), POPF (14.6% vs 13.3%, P = 0.82), length of
hospital stay (5 vs 6 days, P = 0.13), and mortality (2.4%
vs 0.5%, P = 0.29) between the spleen-preserving group
and DP with splenectomy [19]. The laparoscopic group in
this study had a larger percentage of benign cases (87.3%
vs 61.5%, P < 0.01) than the open group.
Other technical considerations include the method of
gland transection and stump closure. Surgical staplers are
the preferred method for both pancreatic gland transection and stump closure. Some surgeons advocate for
staple line reinforcement with a variety of existing products [20]. Absorbable mesh reinforcement of a stapled
pancreatic transection line reduces the leak rate with
distal pancreatectomy [20], but no randomized data exist
to support this maneuver [21]. Gland thickness and
quality and staple height used may be more critical
determinants of adequate stump closure [22]. Another
option recently described is the use of radiofrequency
Laparoscopic pancreatic surgery 325
Figure 23.3 Conversion rate of laparoscopic distal pancreatectomy over time. Note that the conversion rate fell between 2006 and
2009 as the number of cases performed rose. Source: DiNorcia et al. [19]. Reproduced with permission of Springer.
ablation. The advantage of this approach is the efficacy of
sealing the stump [23]. The limitations include damage to
more of the neighboring gland and the expense of the
current devices.
Conversions to the open approach through either an
upper midline or left subcostal incision are most often
indicated for bleeding, adhesions, or presence of malignancy that cannot be managed safely laparoscopically [6]
(Figure 23.3). An intermediate option to consider is the
use of a hand access port if the operation fails to progress
or if there is increasing hemorrhage [7]. Existing data
suggest that the hand access approach may be particularly
useful in obese patients.
18 studies involving 1814 patients, the laparoscopic
approach added an average 19.71 minutes to the time
for the open technique [24]. Song et al. demonstrated
decreased mean operative time from 226 to 190 minutes
for LDP in their center after 20 cases [17]. Several metaanalyses have shown that blood loss is significantly lower
in LDP (263–354.98 mL less, 95% confidence interval
[CI] 529.29 to 180.66, P < 0.001), as is transfusion
rate (odds ratio [OR] 0.28, 95% CI 0.11–0.76,
P = 0.01) [24,25]. Reported conversion rates for indications listed previously are 9.2–11.5% [6,28,29]. An
important bias inherent in these reports is the lack of
randomization, as some of the comparison ODP cases may
not have been suited to a laparoscopic approach.
23.2.3 Outcomes
23.2.3.1 Operative
Meta-analyses of published literature on operative times
comparing LDP and open distal pancreatectomy (ODP)
have not demonstrated statistically significant differences [24–28]. In one analysis from Johns Hopkins of
23.2.3.2 Complications
In their multicenter analysis of 637 DPs, including 159
LPD, the Central Pancreas Consortium (CPC) demonstrated significantly shorter hospital admission days in
the LPD group (5.9 vs 9.0 days, P < 0.01) [30]. An
326 Chapter 23
important aspect of this work was that five of the eight
participating centers were not using the laparoscopic
approach, so the comparison is more likely to be valid.
Other authors have shown a similar trend, with decreases
of 2.7–5 days in hospital length of stay for LPD compared
with OPD [24,26,31]. Venkat et al. reported a decreased
time to oral intake for the LDP group by 1.5 days (95% CI
2.52–0.52, P = 0.003) [24] and Jin and colleagues
showed reduced time to first flatus for this group after
surgery (weighted mean difference 1.80 days, 95% CI
2.14–1.47, P < 0.001) [26].
Venkat et al., in their meta-analysis of 18 studies of LDP
vs ODP, showed the average rate of postoperative morbidity in the LDP group (780 cases) to be 33%, compared
with 44% in the ODP cohort (1034 cases) [24]. Table 23.1
provides summary data for distal pancreatectomy morbidity
ranging from 20% to as high as 50% for minimally invasive
approaches, with the most common complications reported
as intra-abdominal fluid collection (9.6%), surgical site
infection (2.9%), and postoperative hemorrhage (3.5%),
or intra-abdominal abscess (0.8%) [19,24,26,30,32,33].
LDP is a safe procedure with an overall perioperative
mortality rate of 0.4% according to a recent analysis [24].
Thirty-day readmission rate and reoperation rates are
12.6% and 2.1%, respectively [24].
Pancreatic fistula is a common complic ation after
distal pancreatectomy, including LDP, and it is defined
accordingtothe2005ISGPFdefinition as drain output
of any measurable volume on o r after postoperative day
3 with amylase level greater than three times the upper
normal ser um value [41]. Each fistula is classified as A,
B, or C with most sources in the literature denoting B
and C as “ clinically relevant” fistulas. A recent metaanalysis of LDP has demonstra ted a 19.1% overall
incidence of fistulas with 9.5–12.5% being grades B/
C [24,31]. Predictive risk factors for complications from
LDP, including pancreatic fistula, are body mass index
(BMI) >27, pancreatic specimen length >8cm, and
estimated blood loss (EBL) >150 mL [42]. Either
way, the authors feel that compared with ODP, LDP
may not reduce fistula formation but likely will not
increase it either.
23.2.3.3 Pathology
Laparoscopic distal pancreatectomy has been used generally for smaller, benign tumors or indolent malignancies. In an analysis of 360 DPs, DiNorcia reported shorter
average length of pancreas resected (7.7 ± 3.2 cm vs
10.0 ± 3.6 cm, P < 0.01) and smaller median tumor size
(2.5 cm, interquartile range [IQR] 1.5–4.0 cm vs 3.6 cm,
IQR 2.0–6.0 cm; P < 0.01) for LDP cases than for ODP
resection, indicating a surgeon bias for minimally invasive
procedures targeted towards more benign disease. In this
series, the laparoscopic approach was less likely to be used
in patients with adenocarcinoma (4.2% vs 30.2%,
P < 0.01). A review by Jusoh and Ammori demonstrated
comparable numbers of malignant cases between LDP
and ODP series (320 vs 463, P = 0.271) with the majority
of malignant lesions being cystic neoplasms and neuroendocrine tumors. Of note, tumor grade was not reported
in this review [28].
In another large, multicenter study, the CPC compared
short- and long-term outcomes for 23 LDP and 189 ODP
cases in patients with pancreatic ductal adenocarcinoma [37]. There was no significant difference in tumor
size (4.5 ± 2.8 cm vs 3.5 ± 1.3 cm, P = 0.10), total node
retrieval (12.5 ± 8.5 nodes vs 13.8 ± 8.4 nodes, P = 0.47),
positive nodes (1.4 ± 1.9 positive nodes vs 1.0 ± 1.8 positive nodes, P = 0.36), and positive margin percentage
(27% vs 26%, P = 0.98) between LDP and ODP, although
the LDP cohorthad shorter hospitalstay (10.7 ± 6.3 days vs
7.4 ± 3.4 days,P = 0.03). The meta-analysis by Venkatet al.
included four studies on positive margin status, and they
found no significant difference between the LDP (15 of
331, 4.5%) and ODP (45 of 514, 8.8%) groups [24].
Median lymph node extraction via LDP was found to be
significantly lower in one series comparing LDP with ODP
(5.2 vs 9.4, P = 0.04) [36]. Waters et al. showed a similar
trend (14 for LDP vs 11 in ODP) in their analysis of 40
cases [43]. DiNorcia reported that median lymph node
dissection was similar in both the LDP and ODP groups (6,
IQR 2.5–12.0 vs 8, IQR 3.0–13.0, P = 0.29) [19]. These
studies contain heterogeneous pathology and should be
interpreted with caution.
23.2.3.4 Survival
In their 2010 multi-institutional study of 212 patients
undergoing DP for adenocarcinoma, the CPC reported
that, at a median follow-up of 10 months, median actuarial survival was 16 months (range 0–82 months) for all
patients [37]. Method of resection (LDP vs ODP) did not
affect overall survival on multivariate analysis in that
study, leading the authors to conclude that LDP is an
acceptable approach for resection of pancreatic ductal
adenocarcinoma (PDAC) of the left pancreas in selected
patients [37]. Smaller series have described median
Laparoscopic pancreatic surgery 327
Table 23.1 Summary of selected laparoscopic and open distal pancreatectomy in the literature.
Author (year) Conversion
Velanovich (2006) [32] 20 15 15 NR NR 5
Eom et al. (2008) [34] NR 31 62 NR NR 11.5 13.5 36 24 9.7 6.5 0 0 3.95 6.15 9.7 6.5 NR NR NR NR 17.3 46.8 0 1.6
Kooby et al. (2008) [30] 13 142 200 357 588 5.9 9 40 57 11 18 0 1 3.2 3.3 36 49 8 7 NR NR NR NR NR NR
Finan et al. (2009) [35] 12 44 98 157 719 5.9 8.6 NR NR 50 46 0 4.8 3.3 7.7 25 42.3 0 0 NR NR NR NR NR NR
Baker et al. (2009) [36] 3.6 27 85 219 612 4 8 37 35.1 22 14 0 2 3.78 4.03 29 30.1 NR NR 9.4 5.2 NR NR NR NR
Jayaraman et al. (2010) [8] 30 107 236
Kooby et al. (2010) [37] 17 212 189 422 790 7.4 10.7 NR NR NR NR 0 0.9 3.6 3.5 100 100 27 26 14 12.3 10 10 NR NR
Vijan et al. (2010) [38] 4 100 100 171 519 6.1 8.6 34 29 17 17 0 1 3.3 4 23 23 0 0 NR NR NR NR NR NR
DiNorcia et al. (2010) [19] 25.3 71 168 150
Abu Hilal et al. (2011) [39] 0 35 16 200
Limongelli et al. (2012) [40] 6 16 29 160 365 6.4 8.8
Mehta et al. (2012) [33] NR 30 30 294 726 8.7 12.6 50 43.3 16.7 13.3 0 3.3 3.8 4.3 23.3 23.3 NR NR 8.4 13.8 NR NR NR NR
Totals 830 1228
Means 13.09 254.29 617.00 6.77 9.53 33.62 40.22 19.34 19.90 0.00 2.01 3.36 4.30 29.23 37.31 8.98 11.25 8.76 9.26 13.65 28.40 0.00 0.80
LDP, laparoscopic distal pancreatectomy; ODP, open distal pancreatectomy; NR, not reported.
∗
, median reported malignancy.
rate
(%)
No. of
patients
Mean
blood
loss (mL)
Mean
length
of stay
(days)
Postoperative
morbidity
rate (%)
Pancreatic
fistula
rate (%)
Mortality
(%)
Tumor Size
(cm)
Malignant
Histology
(%)
Positive
Margins
(%)
Mean
Median
nodes
(range)
Follow-
up (months)
∗∗∗∗
procured
LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP LDP ODP
∗8∗
20 27 13 13 0 0 NR NR 20 32 NR NR NR NR NR NR 0 0
∗
300∗5∗6∗26 33 15 13 0 0.8 3 3 17 47 3 4 6 7 NR NR NR NR
175
∗
900∗5 6 28.2 43.8 11.3 14.1 0 1 2.5 3.6 12.7 38.5 2.8 13 6 8 NR NR NR NR
∗
394∗7∗11∗40 69 29 44 0 6.3 3.3 3.4 19 11 25 33 NR NR NR NR NR NR
25 41 18 20 0 3 3.2 4.3 36 45 6 7 NR NR NR NR NR NR
Recurrence
∗∗∗∗
(%)
328 Chapter 23
survival of 14–19 months for adenocarcinoma after
LDP [44,45].
23.3 Pancreatic enucleation
Laparoscopic pancreatic enucleations (Lap EN) involve
removal of a lesion from the surrounding pancreatic
parenchyma without formal pancreatic gland resection
(Figure 23.4).
First described by Amikura et al. in 1995, Lap EN is
typically performed for small, benign tumors or those
exhibiting low-grade malignant behavior [46]. These
procedures do not require dissection of the major abdominal vasculature or the creation of surgical anastomoses.
Literature on Lap EN is confined to case reports, small
series, and a few retrospective reviews [44,45,47–49].
While Lap EN is associated with low mortality, this procedure has high morbidity and relatively high incidence
of POPF.
As with formal laparoscopic pancreatic resections,
patient selection for Lap EN is critical to performing the
procedure safely. The literature suggests that the Lap EN
approach is best suited for patients with well-localized,
small (<4 cm in diameter), benign-appearing lesions on
the anterior surface of the pancreas, located at least
2–3 mm away from the main pancreatic duct [50]. The
latter point is important to avoid iatrogenic injury to the
duct during surgery and subsequent pancreatic leak.
Intraoperative ultrasound is a useful adjunct for tumor
characterization and localization in this procedure [50].
The procedure is most commonly used to treat insulinomas; other pathology includes nonfunctioning pancreatic
neuroendocrine tumors, serous and mucinous cystadenomas, solid pseudopapillary tumors, and intraductal
papillary mucinous neoplasms (IPMNs) [51].
Owing to heterogeneity in the literature, operative and
postoperative parameters vary widely. Operating room
(OR) times range from 50 to 405 minutes, conversion
rates to open are 0–75%, and POPF incidences
0–78% [52]. Costi et al. retrospectively examined 29
Lap EN cases performed during a 15-year period at a
single institution, stratifying procedures as simple (enucleation without any other accompanying surgery) or
complex (associated with major accompanying procedure) [49]. In the simple cohort (22 patients), mean
operating time was 144 minutes, average blood loss
112 mL, conversion rate 9%. Overall morbidity was
63%; eight patients (36%) developed POPF and mortality
was 0% [49]. The high morbidity and rate of POPF, even
in simple Lap EN as defined by Costi, are echoed in other
published reports with less homogeneity of analysis.
Figure 23.4 Pancreatic enucleation. Panel (a) shows laparoscopic instruments enucleating a tumor from the anterior surface of the
pancreatic tail. Panel (b) demonstrates how the tumor is away from the main pancreatic duct.
Соседние файлы в папке Библиотека им академика М.И. Перельмана