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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1310_Библиотеки_им_академика_М_И_Перельмана.pdf
24 Laparoscopic Approaches to the Patient … 315
Fascia for the 10–12 mm port site and Pfannestiel incision is closed. All incision
sites are copiously irrigated, followed by skin closure.
Clinical Pearls
• Placing the patient in reverse Trendelenburg position after port placement
aids in visualization of the key structures.
• Intraoperative ultrasound is a valuable tool to assess the tumor margins
and its relationship with vascular structures.
• Caution must be taken when medial-to-lateral dissection is carried out,
given the proximity of the junction of the 4th portion of the duodenum and
early jejunum.
• Due to the patient positioning, the splenic artery may seem to be positioned more anteriorly (even though it is heading to the patient’s left).
• A vascular cartridge for a laparoscopic stapler should be used for pancreatic parenchymal transection and the stapler should be fired using the
slow close technique. If the pancreatic duct is seen it should be oversewn
with a 3–0 silk suture on a tapered GI needle .
There remains debate regarding intraoperative drain placement after pancreatic
resection. Multiple studies have shown that placement of closed suction drains
during pancreaticoduodenectomy does not appear to decrease the rate of secondary
drainage procedures or surgical exploration and, in fact, may be associated with
increased pancreatic fistula (PF) formation and overall morbidity [4–7]. One randomized, controlled trial demonstrated that drains diminish the rate and severity of
pancreatic fistula in patients with moderate/high risk for PF, but this could possibly
be avoided in the roughly one-third of patients with negligible/low risk [8].
Alternative Techniques
RAMPS is an aggressive surgical approach designed to improve oncologic resection with a higher likelihood of negative (tangential) margins, increased rates of
microscopically negative resections, and an improved lymph node dissection. It was
originally described as an open technique in 2003 and then later adapted to
laparoscopic and robotic surgery. Although it may be associated with improved
disease-specific survival, it has similar 5-year overall survi val compared to pancreaticoduodenectomy for adenocarcinoma [1, 9].
Alternative techniques include a laparoscopic hand-assist dist al pancreatectomy
[10, 11], or distal pancreatectomy with splenic preservation [11, 12]. Hand-assist
involves a hand port that allows the surgeon’s hand to access the peritoneal cavity
during surgery. This assists the surgeon to palpate the tumor, allows for manual
316 S.S. Hashmi and D.A. Kooby
retraction and dissection, and application of direct pressure in case there is bleeding.
This technique is usually employed in more difficult cases that involve resection of
larger tumors, tumors with substantial inflammatory reaction around them, or in
obese patients with thick abdominal walls [13].
Distal pancreatectomy with splenic preservation can be performed using what
has been described as the Warshaw technique [11] or Kimura [12]. This involves
either preservation of the splenic vasculature (Kimura) or preservation of the short
gastrics to supply spleen (Warshaw). However, for malignant disease, splenic
preservation at the expense of resection margins or thorough lymph node evaluation
is not recommended.
Alternative Approaches
• RAMPS is an aggressive surgical approach designed to improve oncologic resection with a higher likelihood of negative (tangential) margins,
increased rates of microscopically negative resections, and an improved
lymph node dissection.
• Alternative techniques include a laparoscopic hand-assist distal pancreatectomy or distal pancreatectomy with splenic preservation. For malignant
disease, splenic preservation at the expense of resection margins and
adequate nodal harvest is not recommended.
• Intraoperative drain placement after pancreatic resection remains a great
topic of debate. Closed suction drainage has not been shown to decrease
the rate of secondary drainage procedures or surgical exploration, and may
be associated with increased pancreatic fistula formation and overall
morbidity.
Preoperative Evaluation for Pancreatic Adenocarcinoma
The two main goals of preoperative evaluation are to verify the histopathological
diagnosis of pancreatic cancer and to determine resectability. This usually involves
imaging with any preferred modality, EUS/EUS-guided biopsy, and serum tumor
markers. Multiple imaging modalities are available for the evaluation of suspected
pancreatic cancer, most common being multidetector computed tomography
(MDCT) and magnetic resonance imaging (MRI). Usually the choice of either of
these studies depends on available local expertise and the clinician’s comfort with
one or the other imaging technique, as there is not an evidence-based difference
between the two techniques [ 14, 15]. In some cases, endoscopic decompression
with biliary stent placement may be needed to manage obstructive jaundice
24 Laparoscopic Approaches to the Patient … 317
(particularly for ampullary masses). EUS is a valuable tool for diagnosis. It has a
negative predictive value as high as almost 100% in some series [16, 17].
EUS-guided biopsies help obtain a tissue diagnosis of primary tumor and any
suspicious lymph nodes. These biopsies have been reported to have a high sensitivity (85%) and specificity (98%) for malignancy [18], although the utility may be
limited in pancreatic body tumors. Serum CA 19-9 is a serum biomarker for pancreatic cancer, and has been shown to aid in diagnosis and can be used as a
prognostic marker [19].
Postoperative Care
Postoperative care after LDP is not much different from management of any other
postsurgical patient. Pain management is focused to avoid narcotics to help prevent
ileus. Perioperative antibiotics are continued for 24 h after surgery. Fluid resuscitation is continued for at least 24–36 h, and sometimes longer, until the patient
tolerates a diet. Urine output is used as an objective tool to guide fluid resuscitation.
If the drain output is high, a drain amylase is measured and, if normal, the drain is
removed prior to discharge. If amylase is high, patients are discharged with the
drain and it is removed once the output is low.
Surveillance
The patient usually returns to see the surgeon 2–3 weeks after discharge. At this
visit, the patient’s clinical status is reviewed, their wounds are examined, their
pathology is reviewed, and future care is arranged. Adjuvant chemotherapy with or
without radiation therapy is typically recommended for fit patients following
resection of pancreatic adenocarcinoma, and referral to an oncologist is ensured.
Timing of follow-up visits are then individualized. MRI and serum CA 19-9 levels
are obtained, usually at 1 month after surgery, and then per National Comprehensive Cancer Network guidelines [20].
Overall Management Pearls
• All patients need to undergo a complete staging workup and, only when
no signs of locally advanced or metastatic disease, they are taken to the
operating room for surgical resection.
• If there is any suspicion for metastatic disease at the start of the procedure,
tissue biopsies must be sent for frozen section. If positive for metastases,
surgery should be aborted and the patient should be referred for definitive
chemotherapy.
318 S.S. Hashmi and D.A. Kooby
• Postoperative care after LDP is not much different from management of
any other postsurgical patient.
• Adjuvant chemotherapy, with or without radiation therapy, is typically
recommended for fit patients following pancreatic resection.
Conclusion
About one-fourth of all pancreatic adenocarcinomas are located in the body or tail
of the pancreas, and if they are detected at an early stage these are typically treated
with distal (or left) pancreatectomy. The first reports of LDP were described by
Cuschieri in 1994 [21]. With the recent advances in minimally invasive surgical
techniques, there is an increasing trend in laparoscopic resection of pancreatic
cancer. LDP can be a technically challenging operation, given the need of precise
recognition of tissue planes and the proximity of critical vascular structures. There
are only a few studies that compare open distal pancreatectomy (ODP) and minimally invasive distal pancreatectomy (MIDP) for resection of pancreatic adenocarcinoma. While there are multiple single-center studies [22–27] there is only one
multicenter, case-control led study focused on ductal adenocarcinoma published to
date on this topic by the Central Pancreas Consortium (CPC) in the U.S. Results
from this study showed that while open procedures were found to have higher
estimated blood loss, increased wound infections, and increased need for drainage
postoperatively, no difference was observed in the length of the operation, major
complications, 30-day mortality, and pancreatic fistula development [28].
Although some single-center studies have reported lower positive margin (R1)
rates [24–27], no difference was found in the study from CPC [28]. Based on single
institution and SEER data, a minimum of 12 LNs should be harvested for resections
of pancreatic adenocarcinoma. Only one single-center study shows a significantly
greater node harvest in favor of a minimally invasive approach [23], while other
studies found no significant difference [22–24]. Variable ranges with 5-year survival have been reported, but have not been found to be statistically different. No
significant difference has been found in the use of adjuvant therapy between ODP
and MIDP [22–25, 27, 28]. Table 24.1 shows cumulative results of these studies
discussed above. Minimally invasive approach was used for smaller tumors and
there was a higher incidence of positive margins when an open approach was used.
There is limited data to support that RAMPS approach to distal pancreatectomy
potentially offers increased rates of R0 resections with negative tangential margins
[29–31]. A recent Cochrane review concluded that existing studies investigating
differences between open and laparoscopic approaches are not sufficient to eliminate bias, and randomized studies are needed [32].
24 Laparoscopic Approaches to the Patient … 319
Table 24.1 Cumulative results from studies comparing minimally invasive and open approach to
distal pancreatectomy
Outcome MIDP (minimally invasive distal
N 197 686
Tumor size (cm) 3.4 4
Positive Margin
(%)
Total Nodes 15 12
Adjuvant therapy
(%)
Overall survival 26 months 25 months
Cumulative results from studies comparing minimally invasive and open approach to distal
pancreatectomy (presented at the 12th World Congress of the International Hepato-PancreatoBiliary Association, April 2016, São Paulo 2016)
pancreatectomy)
713
78 76
ODP (open distal
pancreatectomy)
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Robotic Approaches to the Patient with Pancreatic Adenocarcinoma
Jennifer L. Miller-Ocuin, Melissa E. Hogg, Amer H. Zureikat
and Herbert J. Zeh III
Introduction
Pancreatic cancer is a systemic disease in a vast majority of the patients at the time
of diagnosis; this mandates the clinician to carefully consider how to integrate local
control of the tumor into the overall oncologic care of the patient. Current
approaches of open surgery followed by a djuvant therapy have failed to significantly impact overall survival of this disease over the last 30 years. Re-sequencing
of surgery and chemotherapy, integration of more effective chemotherapy regimens,
and minimally invasive approaches to local control have the potential to improve
current poor outcomes. In this chapter, we focus on how robotic pancreaticoduodenectomy is integrated into the multidisciplinary care of the patient with pancreatic
25
J.L. Miller-Ocuin
Department of Surgery, University of Pittsburgh Medical Center,
5112 Centre Avenue, Suite G.21, Pittsburgh, PA 15213, USA
e-mail: millerjl13@upmc.edu
M.E. Hogg A.H. Zureikat
Department of Surgery, Division of Surgical Oncology, University of Pittsburgh
Medical Center, 3550 Terrace Street, Scaife Hall, Suite 497, A-415, Pittsburgh,
PA 15213, USA
e-mail: hoggme@upmc.edu
A.H. Zureikat
e-mail: zureikatah@upmc.edu
H.J. Zeh III (&)
Department of Surgery, Division of Surgical Oncology, University of Pittsburgh
Medical Center, 5150 Centre Avenue, Suite 414, Pittsburgh, PA 15232, USA
e-mail: zehxhx@upmc.edu
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_25
323
324 J.L. Miller-Ocuin et al.
ductal adenocarcinoma. W e will emphasize the diagnostic workup, technique, and
outcomes of robotic-assisted pancreaticoduodenectomy in a patient with pancreatic
adenocarcinoma.
Case Presentation
A 54-year-old male presented to the emergency department with a 3-month history
of epigastric pain, early satiety, nausea and vomiting, and a 15-lb weight loss. His
past medical history was significant for melanoma in situ, diverticulitis, gastroesophageal reflux disease, and hypertension. His family history was negative for
pancreatic diseases and significant for multiple first-degree relatives with melanoma. CT scan without contrast enhancement demonstrated a dilated pancreatic
duct in the setting of an elevated alkaline phosphatase on laboratory analysis.
MRCP, performed to evaluate the pancreatic duct, was suspicious for an ampullary
mass. EUS demonstrated a 2.4 cm mass that was biopsied. He underwent an
endoscopic retrograde cholangiopancreatography (ERCP), demonstrating a distal
common bile duct stricture; sphincterotomy was performed followed by placement
of a 10 mm covered metal stent. He was referred to our multidisciplinary clinic for
further evaluation.
Epidemiology
Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer
deaths in the United States, and remains one of the few disease in which incidence
and mortality remain nearly equal, despite improvements in medical technologies.
Surgery remains the only potentially curative treatment for localized disease [1].
Although contemporary perioperative outcomes in patients undergoing resection for
pancreatic cancer have improved significantly, long-term survival remains largely
unchanged [2]. The poor prognosis of the disease is multifactorial seconda ry to
biological factors [3], delayed presentation, complexity of surgery [4], and lack of
effective therapy [5, 6]. Inherited pancreatic cancer syndromes, comprised of
hereditary pancreatic cancer (identifiable gene mutation) and familial pancreatic
cancer (at least one pair of first-degree relatives without an identifiable gene
mutation), contribute to approximately 5– 10% of all pancreatic adenocarcinoma
cases [7]. Among these, Peutz–Jeghers Syndrome, BRCA2, Lynch Syndrome
(hereditary non-polyposis colon cancer), and—in the case of our patient—familial
atypical multiple mole melanoma syndrome (FAMMMS) should be considered.
25 Robotic Approaches to the Patient with Pancreatic Adenocarcinoma 325
Diagnostic Workup and Staging
All patients should undergo a comprehensive history and physical examination.
Prior abdominal surgery or the presence of underlying comorbidities, such as
chronic obstructive pulmonary disease, or congestive heart failure, should be kept
in mind when choosing patients for minimally invasive pancreatectomy. At our
institution, preoperative planning includes a triphasic (pancreatic protocol) CT scan
of the abdomen and pelvis as well as endoscopic ultrasound (EUS). The combination of these two modalities has proven highly predictive of the ability to achieve
an R0 resection in a validated model [8]. Contrast-enhanced MRI is also an
acceptable imaging modality. These studies should be recent, ideally within 4–6
weeks of surgery [9].
Routine labs include complete blood count, coagulation panel, and hepatic
function panel. We obtain a cancer antigen 19-9 (CA19-9) on all patients at the time
of diagnosis (after serum bilirubin normalizes) and after completion of neoadjuvant
chemotherapy. We have found that a serum CA19-9 response to neoadjuvant
therapy of greater than 50% is predictive of improved overall survival, and is
associated with higher R0 resection rate [10]. At our institution, preoperative
chemotherapy is favored for a majority of patients, thus a short metal stent is
placed.
Our patient had a triple-phase CT scan of the abdomen and pelvis that
demonstrated a 2 cm hypodense mass in the pancreatic head (Fig. 25.1a) that was
abutting the superior mesenteric vein at the splenoportal confluence (Fig. 25.1b).
Endoscopic ultrasound demonstrated a 2.4 cm mass without vascular involvement,
and cytology was consistent with pancreatic adenocarcinoma.
Following normalization of his serum bilirubin, tumor markers were significant
for a cancer antigen 19-9 (CA19-9) of 149 U/ml (normal < 37 U/ml). Based on
criteria from the NCCN, SSO, and AHPBA [11–13 ], the patient was classified as
having resectable pancreatic cancer. The patient was discussed at multidisciplinary
Fig. 25.1 Preoperative imaging demonstrating resectable pancreatic head mass. a Arterial phase
shows hypoenhancing mass in the pancreatic head (arrow). b Portal venous phase demonstrates fat
plane (arrow) between mass and SMV at the level of the splenic vein