Outcomes After Laparoscopic Enucleation of Pancreatic Neoplasms at a Single High Volume Italian Institution

Context Pancreatic enucleation is the best procedure for removing small, benign, solid pancreatic tumors but it can increase the post-operative morbidity. Objective The aim of this study was to analyze our results with 10 consecutive laparoscopic enucleations. Methods The analyzed data were retrospectively collected from 10 consecutive patients who underwent laparoscopic enucleation of a pancreatic neoplasm. Results The mean age was 52.5 years (median 46.3 years). The mass was localized at the body-tail of the pancreas in 90% of the patients and at the head in 10%. The mean operative time was 121 minutes. Intraoperative ultrasonography was performed in 6 cases (60%). One patient (10%) developed a grade A fistula. No other post-operative complications occurred. The conversion and mortality rates were both nil. The mean hospital stay was 6.3 days (median 6 days; range 5-8 days). Histologically all 10 specimens were neuroendocrine pancreatic tumors. The median follow-up was 39 months (range 4-74 months) and no patient has presented tumor recurrence or port site hernia. Conclusions Benign tumors of the pancreas can be radically treated with laparoscopic enucleation. It reduces operative time, hospital stay and overall complication rates. This approach should become the gold standard when there is intent to enucleate a small and presumably benign pancreatic tumor

Robotic Distal Pancreatectomy: Is Hybrid Operation a Viable Approach?

Context Robotic distal pancreatectomy (RDP) is a safe and feasible operation with increasing reports in the literature. The debate is still open whether a hybrid approach could be a viable option versus a fully robotic operation. Objective To analyze the preliminary experience with RDP comparing a hybrid versus a fully robotic approach. Methods All patients undergone RDP were analyzed. A hybrid approach was initially preferred, using laparoscopic harmonic scalpel to perform some steps of operation, including pancreatic gland transection. Patients’ characteristics, pre- and intra-operative data as well as postoperative outcome were prospectively collected in an institutional database. Size of tumor, time of operation and robotic docking, blood loss, post-operative pancreatic fistula (POPF), intra-abdominal fluid collection, and postoperative stay were recorded. Results Five consecutive patients (4 females) underwent RDP between December 2011 and July 2012. Mean age was 55 years (range 34-77 years); mean tumor size was 35 mm (range 10-53 mm). Two spleen preserving RDP were performed. Mean operative time was 275 min (range 210-450 min); robotic procedure time was 158 min (range 60-285 min). One patient was converted to open procedure because of uncontrolled splenic artery bleeding during pancreatic gland transection. Two patients experienced blood loss requiring intra-operative transfusion. One patient was re-operated on because of intra-abdominal fluid collection and partial splenic infarction developed on 5 post-operative day. Two POPF developed (1 grade A and 1 grade B). Mean hospital stay was 13.5 days (range 10-20 days). Histological specimens were consisted of 2 neuroendocrine tumors and 3 mucinous cystadenomas. Two asymptomatic intra-abdominal fluid collections were followed with periodic US investigation and up to now do not necessitate of any active treatment (follow up ended on July 2012). Conclusion A hybrid approach was initially preferred to perform RDP taking origin from more than a decade of experience in laparoscopic distal pancreatectomy. On the basis of overall results obtained we have decided to adopt a fully robotic technique to perform RDP

A Single Centre Experience in Minimally Invasive Surgery for Pancreatic Cystic Lesions

Context Minimally invasive surgery is considered a safe and feasible procedure in selected patients with pancreatic tumors. Objective To present our short-term outcomes of laparoscopic and robotic surgery on pancreatic cystic lesions. Methods A retrospective analysis of hospital records was performed for patients who underwent minimally invasive surgery for suspected pancreatic cystic lesions from May 1999 to May 2013. We analyzed demographics, intraoperative and postoperative course, and pathological details. Results A total of 90 consecutive patients (mean age 42 years) was selected. Eighty-two patients (6 men) underwent laparoscopic distal pancreatectomy (DP) either spleen-preserving (SPDP) or not. Preservation of the spleen was successful in 26 patients over 29. Five women underwent robotic distal pancreatec­tomy (RDP), and in 3 an enucleation was performed. The median operative time was 140 minutes (range: 90-320 minutes) for DP, 240 minutes (range: 210-320 minutes) for RDP, and 85 minutes (range: 75-90 minutes) for enucleation. There was no conversion to open surgery. Two patients required blood transfusions during surgery. Mortality was nil. Pathological examination revealed 3 mucinous cystoadenocarcinomas, 36 mucinous cystadenomas, 28 serous cystadenomas, 14 solid pseudopapillary tumors, 3 IPMNs, 1 pancreatic pseudocyst, 1 adrenal pseudocyst, 1 acinar adenoma, 1 lymphangioma, 1 ciliated cyst, 1 simple cyst. The major morbidity rate was 13% and the minor morbidity rate was 31% (Clavien classification). Pancreatic fistulas developed in 27 patients (30%): 5 were classified as grade C, 6 as grade B, the others as grade A (ISGPF definition). A re-operation was required in 11 cases (12%), 4 due to post-operative hemorrhage, 5 due to sepsis from abdominal abscess, and 2 due to splenic infarction. In patients without complications, the median lenghtb od stay (LOS) was 7.5 days (range: 4-11 days); the ones with a complicated course had a median LOS of 11 days (range: 5-25 days). Conclusions This is the largest single centre series of laparoscopic surgery for cystic lesions in the English literature and confirms safety and feasibility. Robot assisted pancreatic resections is promising and deserves future larger application

Minimally invasive pancreatic surgery - a review

During the past 20 years the application of a minimally invasive approach to pancreatic surgery has progressively increased. Distal pancreatectomy is the most frequently performed procedure, because of the absence of a reconstructive phase. However, middle pancreatectomy and pancreatoduodenectomy have been demonstrated to be safe and feasible as well. Laparoscopic distal pancreatectomy is recognized as the gold standard treatment for small tumors of the pancreatic body-tail, with several advantages over the traditional open approach in terms of patient recovery. The surgical treatment of lesions of the pancreatic head via a minimally invasive approach is still limited to a few highly experienced surgeons, due to the very challenging resection and complex anastomoses. Middle pancreatectomy and enucleation are indicated for small and benign tumors and offer the maximum preservation of the parenchyma. The introduction of a robotic platform more than ten years ago increased the interest of many surgeons in minimally invasive treatment of pancreatic diseases. This new technology overcomes all the limitations of laparoscopic surgery, but actual benefits for the patients are still under investigation. The increased costs associated with robotic surgery are under debate too. This article presents the state of the art of minimally invasive pancreatic surgery

Distal Pancreatectomy With or Without Splenectomy: Indications, Pitfalls and Long Term Outcomes. Results of A Single Center Consecutive Series of 95 Laparoscopic Distal Pancreatectomies

Context There are increasing evidences that spleen preservation is of clinical value for patients undergoing distal pancreatectomy. Laparoscopy appears to increase the rate of spleen preservation through both Warshaw and Kimura techniques. Objective To present early and long term outcomes of a consecutive series of laparoscopic distal pancreatectomies with or without splenectomy and to discuss the pros and cons of spleen preservation. Methods All patients undergone laparoscopic distal pancreatectomy were included in the study. Demographic and clinical characteristics were analyzed. Postoperative complications were prospectively recorded in an institutional database. Long term follow up was assessed by outpatient clinic and direct contact. Follow up ended on May 2012. Results In the Surgical Unit B between May 1999 and December 2011, 95 consecutive patients underwent laparoscopic distal pancreatectomy (76 female, mean age 46.8 years). Conversion rate was 3.2%. En bloc splenectomy was associated in 56 patients (59%). Among 39 patients (41%) with spleen preservation, 9 had a Warshaw procedure. Mortality was nil. Postoperative pancreatic fistula developed in 26% while a re-operation was necessary in 10.5%. In three patients splenectomy was performed during the reoperation. In the long term follow up, 19% of spleen preserving subgroup developed asymptomatic gastric varices. Overall 68% of splenectomized patients adhered to vaccine prophylaxis while one patients who did not, developed a severe sepsis; 13% had a more than 2 years persistent reactive thrombocytosis requiring anti-aggregation therapy. None thromboembolic accident was reported. Conclusion Laparoscopy is a good tool to perform spleen preserving distal pancreatectomy. Spleen preservation per se is a “risk factor” for specific early and late complications with or without splenic vessels sacrifice. Splenectomy leads to an increased risk of infectious and vascular accident adequately preventable by vaccination and anti-aggregation therapy

Laparoscopic distal pancreatectomy: analysis of trends in surgical techniques, patient selection, and outcomes

Background: This study analyzed the time trends of demographic, operative, and pathologic variables in a consecutive series of patients undergoing laparoscopic distal pancreatectomy (LDP). In addition, we assessed the parameters potentially related to the learning curve, and evaluated the long-term outcomes. Methods: LDP performed between 1999 and 2012 (minimum follow-up of 1\ua0year) were included in the study. The time trends were studied categorizing the operative sequence in three equal groups, and the parameters related to the learning curve were assessed using local regression techniques. All the analyses were stratified by operation type (associated splenectomy vs. spleen-preserving procedures). Results: The study population consisted of 100 patients. There were 57 LDP with associated splenectomy and 41 spleen-preserving LDP; conversion was necessary in 2 cases. The time trend analysis showed that there was not a tendency toward broadening the indications or selecting more difficult cases. Similarly, the study of learning curve components did not show any significant variation over time. Only 45 splenectomized patients received prophylactic vaccinations, and one unvaccinated patient developed an overwhelming post-splenectomy infection. At a median follow-up of 72.5\ua0months, 12 patients developed diabetes mellitus, while 8 patients undergoing spleen-preserving LDP developed gastric and perigastric varices. Conclusion: This analysis did not identify parameters related to the patient selection process and the learning curve in LDP. The incidence of new-onset diabetes was lower than reported in other series. The possibility of serious infections following splenectomy has to be taken into account, such that a strict adherence to vaccine protocols is strongly recommended

A prospective non-randomised single-center study comparing laparoscopic and robotic distal pancreatectomy

Laparoscopic distal pancreatectomy (LDP) is increasing in popularity thanks to the benefits that have been recently demonstrated by many authors. The Da Vinci(A (R)) Surgical System could overcome some limits of laparoscopy, helping the surgeons to perform safer and faster difficult procedures. Nowadays, prospective clinical trials comparing LDP to robotic distal pancreatectomy (RDP) are lacking. The aim of this study is to present a prospective comparison between the two techniques.Since November 2011, all patients suitable for minimally invasive distal pancreatectomy were assigned either to LDP or RDP, depending on the availability of the Da Vinci(A (R)) Surgical System for our Surgical Unit. Demographics, clinical, and intra- and postoperative data, including estimated costs of the procedure, were prospectively collected. Follow-up included cross-sectional imaging ended on April 2014.Twenty-two patients underwent RDP and 21 LDP; patients' characteristics were similar. The median operative time was longer and procedures' cost was double in RDP group. The conversion to open rate and the median length of postoperative hospital stay were 4.5 % and 7 days, respectively, in both groups. Pancreatic fistula developed in 57.1 % (12/21) and 50 % (11/22) of LDP and RDP, respectively (p = 0.870), being grade A the most frequent. Mortality was nil and an R0 resection was achieved in all Patients. The overall number of lymph nodes harvested was similar between the two groups.Both RDP and LDP are valid techniques for the treatment of distal pancreatic tumors. The advantages of RDP are claimed by many but still under investigation. Some of these advantages are more subjective than objective, and it seems difficult to demonstrate a real superiority of one technique over the other in a standardized fashion. In our experience, laparoscopy has not been abandoned in favor of the robot: we continue to perform both approaches choosing upon single patient's characteristics

Laparoscopic and Robot-Assisted Surgery for Pancreatic Neuroendocrine Tumors: Single-Center Experience

Context Pancreatic neuroendocrine tumors (pNET) in many cases are small and could be considered well suited for removal by minimally invasive approach. There are few large series that describe the technical feasibility, outcome and histo­pathology associated with laparoscopic (LS) and robot-assisted (RA) pancreatic surgery. Objective To evaluate the efficiency of minimally invasive surgery for pNET, considering the revolutionary field of RA pancreatic surgery. Methods We performed a retrospective analysis of all minimally invasive pancreatic resections (LS and RA) at Pancreas Institute of Verona between January 2002 and May 2013. We reviewed operative management information and compared clinical and histological data with short- and long-term outcomes. Standard statistical methods were used. Results Fifty consecutive patients were selected (26 females, 24 males), with a median age of 55 years (IQR: 24-81 years). Forty-three LS procedures were performed: 17 distal pancreatectomies with splenectomy (DPS), 12 spleen-preserving distal pancreatectomies (DS), 12 enucleations (En), and 2 middle pancreatectomies (MP). Seven procedures were performed robotically: 3 DS, 3 DPS, 1 En. Five patients (10%) required conversion to open surgery. The median operative time of En was 125 min (IQR: 100-166 min), of DPS, DS and MP was 210 min (IQR: 150-240 min). Pancreatic fistula rate was 32% (6 cases classified by ISGPF as grade A, 8 grade B, and 2 grade C). The median hospital stay was 7 days (IQR: 6-10 days). All but one resections were R0. On histological examination, median size of pNET was 17.5 mm (IQR: 12.2-29.2 mm); 10 were functioning pNET (9 insulinomas, 1 ACTH); 37 were G1 pNET, 12 G2 and 1 G3; regional lymph­adenectomy was performed in 20 DPS, with a median of 13 lymphnodes removed and a Ln Ratio of 0.05. No patient developed recurrences or metastases. Conclusion The present study confirms that LS and RA pancreatic resections for pNET are feasible, with comparable morbidity, fistula formation and oncological results to that observed after open surgery, but with all known advantages of minimally invasive techniques. The crucial point is the right pre-operative evaluation and selection of each patient