Page 144 - Read Online

Basso et al. Mini-invasive distal pancreatectomy

DISCUSSION (OS), between the laparoscopic and open approach.

The laparoscopic approach to pancreatic surgery has An important issue concerning oncologic effectiveness
been utilized increasingly in the last decade, as a result of minimally invasive surgery is that of achieving
of the evolution of minimally invasive technologies microscopically negative margins (R0) and an adequate
and the increasing numbers of pre-malignant and number of harvested lymph nodes. Several reports
incidentally detected pancreatic lesions. However, have addressed this topic, and different comparative
[11]
a population-based analysis on the Nationwide studies found no significant differences of R0 rates
Inpatient Sample (NIS) found that, during the period between laparoscopic and open techniques (74-97%
[21]
[20]
1998 to 2009, only 4.3% of distal pancreatectomies vs. 73-96%). Abu Hilal et al. reported a 76% of
were performed with a minimally invasive approach. R0 and a median of 15 sample nodes, suggesting that
[12]
Technical difficulties, due to the retroperitoneal their standardised technique was a reasonable and
location of the pancreas and the scarcity of high- safe procedure in left-sided malignancies. Shin et al.
[22]
volume skilled surgical teams, as well as the need to reported a rate of R0 resections of 82.9% in 152 left
maintain oncologic standards, were major obstacles pancreatic lesions, with a median size of 3 cm, removed
to the adoption of the laparoscopic approach. [5] with minimally invasive access. Another recent series of
distal pancreatectomies showed similar results in terms
More recently, several studies and meta-analyses have of R0/R1/R2 rates, and a median of 16 harvested lymph
shown that LDP is a safe procedure, with improved nodes in LDP vs. 14 in ODP. Fernandez-Cruz et al.
[13]
[23]
outcomes and reduced hospital stays. [13-16] Cao et al. performed 27 LDP, achieving an R0 resection in 90% of
[12]
in their population-based retrospective cohort study ductal adenocarcinomas, and removing a median of 6
reported a reduction of 1.22 days in LoS associated lymph nodes in the LDP group vs. 8 in the ODP group.
with minimally invasive surgery, with no differences Interestingly, in our series, the number of removed
in the perioperative mortality and total hospital costs. lymph nodes was similar and adequate in both groups,
Furthermore, lower rates of infectious complications despite benign and malignant diseases having been
(30.1% vs. 39%) and bleeding complications included (10.55 ± 4.3 vs. 12.08 ± 3.12, P = NS). Notably,
(13.1% vs. 20.6%) were reported in LDP vs. ODP. data on pancreatic ductal adenocarcinoma suggest
Unfortunately, no randomized controlled trials (RCTs) that a minimum of 12 lymph nodes should be excised
[24]
comparing the two approaches are available, and all to ensure adequate nodal assessment. However, this
favourable results are reported in retrospective cohort- point is still debated, and the oncologic effectiveness
like or case-control studies. [17] of the minimally invasive approach still worries some
surgeons. In the USA, high-volume centres perform
Our retrospective analysis was performed on a distal pancreatectomies with minimally invasive
series of well-matched patients, with comparable techniques, either laparoscopic or robotic, unless there
demographics and similar histologic findings [Table 1]. are clear contraindications present. However, according
In our experience, pancreatic NET and cystic tumours to a recent survey, 31% of European surgeons still
were the main result at definitive histology, and a prefer ODP for oncologic purposes. [12,25]
distal minimally invasive pancreatic resection was
the surgical approach of choice for such indolent In our series, ASA score and BMI were similar in the
malignancies. The treatment of these rare diseases two groups and, in contrast to other studies, patients
requires expertise in both pancreatic surgery and who were treated with LDP had similar tumour size as
advanced laparoscopy, but unfortunately, the number those treated with open approach (5.33 ± 3.2 vs. 5.58 ±
of retrospective reports is limited, and the complete 2.57 cm, P = NS). In previous studies, the laparoscopic
information, including tumour size and margin status, approach was primarily used for small benign lesions
are often missing. [18] or indolent malignancies. In a series of 360 distal
pancreatic resections, 71 were totally laparoscopic but
However, the progressive centralization of the had a significantly smaller median tumor size (2.5 cm in
surgical treatment of patients with pancreatic LDP vs. 3.6 cm in the ODP group). [26] Similarly, another
disease in specialized and high-volume centres will systematic review reported a mean tumor size of 3.5 cm
favour implementation of the procedure and data in LDP vs. 3.9 cm in ODP. In our experience, the size
[27]
availability. A multicentre analysis, performed in 2010 of the specimen was not a contraindication or a major
by Kooby et al., reported similar oncologic results obstacle to laparoscopic approach, but had an impact
[6]
between LDP and ODP, with no differences in terms on the duration of surgical intervention. It is noteworthy
of overall survival and lymph node yield. Similarly, that there is a recent trend toward an increased size
DiNorcia et al. in 130 resections for PNET, reported of the excised lesions (4.0 ± 2.8 cm vs. 3.3 ± 1.5 cm)
[19]
no differences in morbidity, mortality, or overall survival noted in the literature. [20]
Mini-invasive Surgery ¦ Volume 1 ¦ September 30 137