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Background:
The aims of this study were to compare splenic vessel patency between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy (SSVpDP), and to identify possible risk factors for poor splenic vessel patency.
Methods:
This retrospective multicenter study included 116 patients who underwent laparoscopic (n = 70)...
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Methods
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Purpose
This study aimed to investigate whether clinical outcomes varied based on the tumor location within the pancreatic body and tail in patients with pancreatic cancer (PC).
Methods
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Laparoscopic distal pancreatectomy is currently a commonly performed procedure. Twenty-five retrospective studies comparing laparotomy and laparoscopy have dealt with the feasibility of this approach for localized benign and malignant tumors. However, these studies report several different techniques. The aim of this review was to determine if a st...
Introduction: Laparoscopic spleen-preserving distal pancreatectomy for tumors of the pancreatic body and tail is becoming increasingly established at hepato-pancreato-biliary surgical departments worldwide. Spleen preservation is only recommended in benign or borderline lesions of the pancreas. We present a rare complication after laparoscopic sple...
Background
Radical antegrade modular pancreatosplenectomy (RAMPS) is an isolation procedure in pancreatosplenectomy for pancreatic body/tail cancer. Connective tissues around the bifurcation of the celiac axis are dissected, followed by median-to-left retroperitoneal dissection. This procedure has the potential to isolate blood and lymphatic flow t...
Citations
... Bleeding is one of the biggest challenges of laparoscopic pancreatic body and tail surgery (12). Effective control of the hemorrhage is the key to successful implementation of the operation. ...
Background:
In the process of laparoscopic splenic vessels and spleen preservation distal pancreatectomy (LsvSPDP), because the splenic blood vessels have many small branches, how to safely separate the splenic blood vessels from the pancreas has always been the focus and difficulty of this operation. Many cases were switched to laparotomy, or the Warshaw method due to the inability to control bleeding during the separation of the splenic blood vessels. Therefore, we tried to use the selective splenic vascular control method when separating the splenic blood vessels to observe its effect on the conditions of the surgical patients during and after the operation.
Methods:
We retrospectively collected 35 cases of LsvSPDP conducted in our center from September 2015 to December 2020, including 5 males and 30 females. Considering the influence of the surgical learning curve, the cases were divided into three groups. Finally, through statistics of its intraoperative and postoperative conditions, the effectiveness of selective splenic vascular control method can be judged.
Results:
Patients in Group 2 and 3 showed significantly less blood loss (172.5 and 134.44 mL, respectively) compared to patients in Group 1 (541.43 mL; P=0.01). However, the amount of blood loss was not significantly different between Group 2 and 3.
Conclusions:
The amount of bleeding was significantly reduced by splenic blood vessel control technology. And it can improve the success rate of spleen preservation, preserve the success rate of splenic blood vessels, and reduce intraoperative bleeding.
... Keywords Laparoscopic pancreaticoduodenectomy · Learning curve · Risk-adjusted CUSUM Since laparoscopic distal pancreatectomy, LDP [1] and laparoscopic pancreaticoduodenectomy, LPD [2] were introduced in 1994, both procedures have been adopted but with different penetration rates. LDP has become the standard operative procedure for benign and borderline malignant lesions located in the left pancreas, with a recent expansion of its indication to malignant lesions [3][4][5]. In contrast, LPD has been adopted more slowly and is still limited to a few highly experienced surgeons in high-volume centers due to its very technical procedures and concerns over its high morbidity and mortality rates [6][7][8][9][10]. ...
Background
Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding and there is much controversy about its safety. We evaluated the learning curve for pure LPD based on the clinical outcomes of consecutive patients treated by a single surgeon.Methods
We reviewed the medical records of 119 consecutive patients who underwent LPD by a single surgeon between June 2013 and August 2018. The learning curve was evaluated using the cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Perioperative outcomes were compared among the learning curve phases.ResultsCUSUM analysis of the operation time showed that the operation time improved after the 47th case. RA-CUSUM analysis showed the learning curve for surgical failure, defined as severe complications (Clavien–Dindo grade ≥ 3) or open conversion, comprised three phases (phase 1: cases 1–60; phase 2: cases 61–83; phase 3: cases 84–119). There were no significant differences in operation time among the three phases. Intraoperative blood loss decreased significantly over the three phases (P = 0.032). There were no postoperative deaths. The rates of postoperative complications, pancreatic fistula (grade B/C), and post-pancreatic hemorrhage were significantly lower in phase 3 than in phase 2 (2.8% vs. 21.7%, P = 0.019; 2.8% vs. 17.4%, P = 0.049; 0% vs. 13.0%, P = 0.026), but not between phases 1 and 2. Postoperative hospital stay decreased progressively, and was significantly shorter in phase 3 than in phase 1 (9.1 vs. 16.7 days, P = 0.001).Conclusions
The LPD failure rate decreased after the first 60 cases and stabilized after 84 cases. For safe dissemination of LPD, it is important to shorten the long learning curve and decrease the unfavorable outcomes in the early phase of the learning curve.
... Often, surgeons try to adopt the former approach to preserve the splenic vessels, due to the significantly increased risks of splenic infarction and gastric varices when the splenic vessels are sacrificed. [12][13][14][15][16] Multiple studies have compared laparoscopic SPDP versus open SPDP with conflicting results, with some describing poorer splenic vein patency in laparoscopic SPDP as compared to open SPDP [17] and yet others describing high patency rates and low splenic infarction rates with laparoscopic SPDP. [18,19] Numerous studies have also compared robotic versus laparoscopic approaches for distal pancreatectomy, showing that the robotic approach is a safe and feasible alternative approach with comparable perioperative and oncological outcomes compared to that of the laparoscopic approach, [20][21][22][23][24] and may even have better spleen and vessel preservation rates. ...
... Splenic perfusion was classified into four grades according to the extent of the splenic infarction as a percentage of the total splenic volume: Grade 0, intact; Grade 1, <50% infarction; Grade 2, ≥50% infarction and Grade 3, 100% infarction. [17,31] All post-operative computed tomography images were compared with pre-operative images to evaluate post-operative changes in vascular patency. ...
... Moreover, veins are typically more susceptible to thrombosis and inflammation compared to arteries, given their thinner walls and lower velocity of blood flow. [7,32] Several studies have compared laparoscopic SPDP versus open SPDP with conflicting results, with some describing poorer splenic vein patency in laparoscopic SPDP as compared to open SPDP, [17] whereas others have reported higher patency rates and lower splenic infarction rates with laparoscopic SPDP. [18,19] Several authors have also compared robotic versus laparoscopic approaches for distal pancreatectomy and have reported that the robotic approach is a safe and feasible alternative approach with comparable perioperative and oncological outcomes compared to that of the laparoscopic approach. ...
Introduction:
This study aimed to compare the perioperative outcomes of patients who underwent minimally invasive spleen-preserving distal pancreatectomy (MI-SPDP) versus open surgery SPDP (O-SPDP). It also aimed to determine the long-term vascular patency after spleen-saving vessel-preserving distal pancreatectomies (SSVDPs).
Methods:
A retrospective review of 74 patients who underwent successful SPDP and met the study criteria was performed. Of these, 67 (90.5%) patients underwent SSVDP, of which 38 patients (21 open, 17 MIS) had adequate long-term post-operative follow-up imaging to determine vascular patency.
Results:
Fifty-one patients underwent open SPDP, whereas 23 patients underwent minimally invasive SPDP, out of which 10 (43.5%) were laparoscopic and 13 (56.5%) were robotic. Patients who underwent MI-SPDP had significantly longer operative time (307.5 vs. 162.5 min, P = 0.001) but shorter hospital stay (5 vs. 7 days, P = 0.021) and lower median blood loss (100 vs. 200 cc, P = 0.046) compared to that of O-SPDP. Minimally-invasive spleen-saving vessel-preserving distal pancreatectomy (MI-SSVDP) was associated with poorer long-term splenic vein patency rates compared to O-SSVDP (P = 0.048). This was particularly with respect to partial occlusion of the splenic vein, and there was no significant difference between the complete splenic vein occlusion rates between the MIS group and open group (29.4% vs. 28.6%, P = 0.954). The operative time was statistically significantly longer in patients who underwent robotic surgery versus laparoscopic surgery (330 vs. 173 min, P = 0.008).
Conclusion:
Adoption of MI-spleen-preserving distal pancreatectomy (SPDP) is safe and feasible. MI-SPDP is associated with a shorter hospital stay, lower blood loss but longer operation time compared to O-SPDP. In the present study, MI-SSVDP was associated with poorer long-term splenic vein patency rates compared to O-SSVDP.
... Although it was well accepted that splenic vesselpreserving DP can reduce spleen-related complications due to conservation of the splenic vessel, compared to Warshaw's technique, splenic vessels may fail to remain patent as a result of thermal damage by ultrasonic shear or vascular manipulations during the surgery. Therefore, some researchers have suggested that it would be beneficial to convert to Warshaw's procedure during the splenic vessel-preserving DP surgery if the dissection for conserving the splenic vessels is anticipated to be difficult and require frequent vascular manipulation [79,81]. ...
Background
Pancreatic resections are complex and technically challenging surgical procedures. They often come with potential limitations to high-volume centers. Distal pancreatectomy is a relatively simple procedure in most cases. It facilitates the development of up-to-date minimally invasive surgical procedures in pancreatic surgery including laparoscopic distal pancreatectomy and robot-assisted distal pancreatectomy.
Main body
To obtain a desirable long-term prognosis, R0 resection and adequate lymphadenectomy are crucial to the surgical management of pancreatic cancer, and they demand standard procedure and multi-visceral resection if necessary. With respect to combined organ resection, progress has been made in evaluating and determining when and how to preserve the spleen. The postoperative pancreatic fistula, however, remains the most significant complication of distal pancreatectomy, with a rather high incidence. In addition, a safe closure of the pancreatic remnant persists as an area of concern. Therefore, much efforts that focus on the management of the pancreatic stump have been made to mitigate morbidity.
Conclusion
This review summarized the historical development of the techniques for pancreatic resections in recent years and describes the progress. The review eventually looked into the controversies regarding distal pancreatectomy for tumors in the body and tail of the pancreas.
... P = 0.006), and hospital stay was significantly shorter in the laparoscopic group (7 days vs. 9 splenectomy for splenic complication [11,12]. There were some studies regarding comparisons of splenic vessel patency after distal pancreatectomy between open and laparoscopic group; however, some discrepancies existed among them [3,13,14]. As a result, the purpose of this study is to compare splenic vessel patency after laparoscopic or open splenic vessel-preserving distal pancreatectomy. ...
... thrombosis is associated with postoperative pancreatic fistula [20]. Yoon et al. [13,14] said that laparoscopic group showed lower splenic vein patency than open group. Especially, during laparoscopic surgery, there are more difficult and meticulous dissections for the splenic vein. ...
Purpose
This study compared the patency of the splenic vessels between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy.
Methods
We retrospectively reviewed a database of 137 patients who underwent laparoscopic (n = 91) or open (n = 46) spleen and splenic vessel-preserving distal pancreatectomy at a single institute from 2001 through 2015. Splenic vessel patency was assessed by abdominal computed tomography and classified into three grades according to the degree of stenosis.
Results
The splenic artery patency rate was similar in both groups (97.8 vs. 95.7%, P = 0.779). Also, the splenic vein patency rate was not significantly different between the 2 groups (74.7% vs. 82.6%, P = 0.521). Postoperative wound complication was significantly lower in the laparoscopic group (19.8% vs. 28.3%, P = 0.006), and hospital stay was significantly shorter in the laparoscopic group (7 days vs. 9 days, P = 0.001) than in the open group. Median follow-up periods were 22 months (3.7–96.2 months) and 31.7 months (4–104 months) in the laparoscopic and open groups, respectively.
Conclusion
Laparoscopic distal pancreatectomy showed good splenic vessel patency as well as open distal pancreatectomy. For this reason, splenic vessel patency is not an obstacle in performing laparoscopic splenic vessel-preserving distal pancreatectomy.
... The recent improvement of minimally invasive surgical techniques has resulted in an increased amount of laparoscopic and robotic surgery for pancreatic diseases. Many studies have reported that the laparoscopic distal pancreatectomy (LDP) technique is safe and cases of LDP are increasing [1][2][3]. LDP is mainly performed in patients with benign/ borderline pancreatic disease. Most surgeons prefer the use of this spleen-preserving technique. ...
Background:
Laparoscopic distal pancreatectomy (LDP) is generally the treatment of choice for diseases of the pancreatic body and tail. Most surgeons prefer the spleen- and splenic vessel-preserving technique (SPVP-LDP) in benign/borderline pancreatic disease because complications of splenic infarction and gastric varices can arise after Warshaw technique. This study was aimed to determine the true learning curve of the SPVP-LDP procedure not LDP including Warshaw technique.
Methods:
Data were collected retrospectively from all patients who underwent a LDP between June 2007 and April 2017 at Gangnam Severance Hospital. We used cumulative sum control chart (CUSUM) analysis to assess the learning curve for the SPVP-LDP technique.
Results:
Eight-three patients were performed LDP and we excluded patients who underwent robotic approach (N = 10) and open conversion DP (N = 8). Patients who underwent SPVP-LDP procedures were categorized into Group 1 (primary end-point). Those who underwent LDP procedures with splenectomy and the Warshaw technique were categorized into Group 2. We found that the 16th case was the cutoff point and the mean length of hospital stay was 13.0 days in the first period and 8.7 days in the second period (p = < 0.001).
Conclusions:
These results indicated that the frequency of SPVP-LDPs had increased and that technological progress had been made over time. The true learning curve for SPVP-LDP was indicated as 16 cases in a group of surgeons with no experience of laparoscopic pancreatic surgery.
... However, there is a risk of bleeding from the splenic vessels during the procedure used to isolate their small branches. Furthermore, when bleeding from the splenic vessels occurs during dissection, improper manipulation of the splenic vessels and inappropriate hemostasis may impair the patency of the preserved splenic vessels, which increases the risk of left-sided portal hypertension [10,11]. We have recently performed a blunt dissection technique using the LigaSure vessel-sealing device (Medtronics, Minneapolis, MN, USA) during laparoscopic spleen-and splenic-vessel-preserving distal pancreatectomy, as introduced by Suzuki et al. to reduce the risk of bleeding during the dissection of the splenic vessels [12]. ...
Background:
We have recently performed a blunt dissection technique using LigaSure technology for laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy to reduce the risk of bleeding during the dissection of the splenic vessels. The aim of this study was to compare the utility of the blunt dissection technique and a conventional dissection technique during laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy.
Methods:
Fifty-five patients who underwent laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy performed by a single surgeon between March 2003 and December 2015 were enrolled in this retrospective single-center study. The patients were divided into the LigaSure group (n = 23) and non-LigaSure group (n = 26). Perioperative clinical outcomes and the postoperative patency of the preserved splenic vessels in the two groups were compared.
Results:
The patient and tumor characteristics did not differ significantly between the two groups. The incidence of postoperative complications was similar in the two groups. However, the mean operative time (145 vs. 231.1 min, P = 0.001), intraoperative blood loss (95.6 vs. 360 ml, P = 0.001), and postoperative hospital stay (6.4 vs. 9.8 days, P = 0.001) were significantly lower in the LigaSure group than in the non-LigaSure group, respectively. The splenic artery patency rate was similar in both groups, but the splenic vein patency was significantly better in the LigaSure group than in the non-LigaSure group (total occlusion rate: 4.5 vs. 30.8%, respectively, P = 0.017).
Conclusion:
The results of this study suggest that the blunt dissection technique using a LigaSure reduces the operating time and intraoperative blood loss during laparoscopic spleen- and splenic-vessel-preserving distal pancreatectomy and increases the patency of the preserved splenic vessels.
... Splenic infarct can lead to either auto-splenectomy or the need to return to the operating room for a formal splenectomy. Kimura technique preserves the main splenic vasculature, which likely results in better perfusion of the spleen and a reduced chance of infarct [42]. ...
Background:
Distal pancreatectomy (DP) is performed to treat tumors of the pancreatic body and tail. Traditionally, splenectomy is performed with a DP, however, laparoscopic spleen-preserving DP (SPDP) using Warshaw's (splenic vessels ligation) or Kimura's (splenic vessels preservation) techniques have been reported. The clinical benefits of using either technique remain unclear. In this study, we conducted a meta-analysis to compare the clinical outcomes of patients undergoing Warshaw's and Kimura SPDP. This is the first study to evaluate the geographical variation in outcomes of Warshaw's and Kimura SPDP.
Methods:
Databases of PubMed, Embase, and Cochrane library were used to identify studies reporting Warshaw's and Kimura SPDP. Clinical outcomes were compared. Pooled odds risk and weighted mean difference with 95% confidence interval were calculated using random effect models.
Results:
Fourteen non-randomized controlled studies involving 945 patients met our selection criteria. 301 (31.9%) patients underwent Warshaw's SPDP; 644 (68.1%) underwent Kimura SPDP. Compared to Warshaw's SPDP, patients undergoing Kimura SPDP had a lower incidence of post-operative complications including spleen infarction (OR = 9.64, 95% CI = 5.79 to 16.05, P < 0.001) and gastric varices (OR = 11.88, 95% CI = 5.11 to 27.66, P < 0.001). The length of surgery was significantly shorter for Warshaw's SPDP (WMD = -18.12, 95%CI = -26.52 to -9.72, p < 0.001). Decreased blood loss was reported for patients undergoing Warshaw's SPDP (WMD = -59.72, 95%CI = -102.01 to -17.43, p = 0.006). There were no differences between the two groups' rates of conversion to an open procedure (P = 0.35), postoperative pancreatic fistula (P = 0.71), need for reoperation (P = 0.25), and length of hospital stay (P = 0.38).
Conclusion:
Both Warshaw's and Kimura are safe SPDP techniques. These data suggest Kimura SPDP is the preferred technique due to less risk of splenic infarct and gastric varices. Despite evidence of regional variation in volume performed (between Kimura and Warshaw's), there are no statistically significant differences in outcomes between these techniques.
... However, it took more than 10 years until the first comparative series on LDP vs open distal pancreatectomy (ODP) were published [4,5]. Comparative studies for non-malignant diseases found similar baseline characteristics such as age, BMI, and tumor size, although Yoon et al. reported younger patients in the laparoscopic group [6][7][8][9][10][11][12][13]. Recent nationwide evaluation in the US suggests that benign disease and BMI of 30-40kg/m 2 have been the selection factors for minimally invasive technique, whereas pancreatic ductal adenocarcinoma (PDAC), tumor size > 5 cm, and multivisceral resections resulted in ODP [14]. ...
... Most of the comparative studies found 1-2 h longer operative time for laparoscopy [6][7][8][9][10][11][12][13], but only in three of those, the difference was statistically significant [6,7,12]. On the other hand, estimated blood loss (EBL) decreased with 200-300 mL by LDP [6][7][8][9][10][11][12][13], and two studies found that LDP was associated with higher spleen preservation rate [7,8]. ...
... Most of the comparative studies found 1-2 h longer operative time for laparoscopy [6][7][8][9][10][11][12][13], but only in three of those, the difference was statistically significant [6,7,12]. On the other hand, estimated blood loss (EBL) decreased with 200-300 mL by LDP [6][7][8][9][10][11][12][13], and two studies found that LDP was associated with higher spleen preservation rate [7,8]. LDP was not shown to reduce the postoperative morbidity, although some studies still suggest lower rate of complications compared with ODP [11,12]. ...
Background: Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.
Methods: An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey.
Results: LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case–control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe.
Conclusions: LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.
... Regarding the spleen-preserving rate, results stated that it is worth to attempt laparoscopic spleen-preserving DP in patients with a presumed benign to borderline tumor of the body-tail of the pancreas [54]. The most positive results were reported for the splenic vessels preservation technique regarding the conservation of the spleen [51,66]. With growing surgical experience and refinement in the surgical technique, the indications for LDP have substantially broadened [52]. ...
Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer-related deaths. Surgery is the only viable treatment, but irradical resection rates are still high. Laparoscopic pancreatic surgery has some technical limitations for surgeons and tumor identification may be challenging. Image-guided techniques provide intraoperative margin assessment and visualization methods, which may be advantageous in guiding the surgeon to achieve curative resections and therefore improve the surgical outcomes. In this chapter, current available laparoscopic surgical approaches and image-guided techniques for pancreatic surgery are reviewed. Surgical outcomes of pancreaticoduodenectomy and distal pancreatectomy performed by laparoscopy, laparoendoscopic single-site surgery (LESS), and robotic surgery are included and analyzed. Besides, image-guided techniques such as intraoperative near-infrared fluorescence imaging and surgical navigation are presented as emerging techniques. Results show that minimally invasive procedures reported a reduction of blood loss, reduced length of hospital stay, and positive resection margins, as well as an improvement in spleen-preserving rates, when compared to open surgery. Studies reported that fluorescence-guided pancreatic surgery might be beneficial in cases where the pancreatic anatomy is difficult to identify. The first approach of a surgical navigation system for guidance during pancreatic resection procedures is presented, combining preoperative images (CT and MRI) with intraoperative laparoscopic ultrasound imaging.
