Oncological outcomes in minimally invasive vs. open distal pancreatectomy: a systematic review and network meta-analysis.

Background: Advancements in surgical techniques have improved outcomes in patients undergoing pancreatic surgery. To date there have been no meta-analyses comparing robotic and laparoscopic approaches for distal pancreatectomies (DP) in patients with pancreatic adenocarcinoma (PDAC). This systematic review and network meta-analysis aims to explore the oncological outcomes of laparoscopic distal pancreatectomy (LDP), robotic distal pancreatectomy (RDP) and open distal pancreatectomy (ODP). Methods: A systematic search was conducted for studies reporting laparoscopic, robotic or open surgery for DP. Frequentist network meta-analysis of oncological outcomes (overall survival, resection margins, tumor recurrence, examined lymph nodes, administration of adjuvant therapy) were performed. Results: Fifteen studies totalling 9,301 patients were included in the network meta-analysis. 1,946, 605 and 6,750 patients underwent LDP, RDP and ODP respectively. LDP (HR: 0.761, 95% CI: 0.642-0.901, p = 0.002) and RDP (HR: 0.757, 95% CI: 0.617-0.928, p = 0.008) were associated with overall survival (OS) benefit when compared to ODP. LDP (HR: 1.00, 95% CI: 0.793-1.27, p = 0.968) was not associated with OS benefit when compared to RDP. There were no significant differences between LDP, RDP and ODP for resection margins, tumor recurrence, examined lymph nodes and administration of adjuvant therapy. Conclusion: This study highlights the longer OS in both LDP and RDP when compared to ODP for patients with PDAC. Systematic Review Registration: https://www.crd.york.ac.uk/, PROSPERO (CRD42022336417).

Comparison of perioperative and oncologic outcomes after open, laparoscopic, and robotic distal pancreatectomy: a single-center retrospective study.

As minimally invasive surgery gains grounds, surgeons are switching more towards laparoscopic distal pancreatectomy (LDP) and robotic distal pancreatectomy (RDP) as opposed to open distal pancreatectomy (ODP). Through this study, we aimed at exploring the differences in perioperative and oncologic outcomes among the three surgical methods. We retrospectively collected data from 303 patients who underwent distal pancreatectomy (DP) at a single high-volume institution between June 2015 and December 2021. We equally compared the perioperative and oncologic outcomes in patients who underwent ODP, LDP, and RDP by analyzing clinicopathologic and survival data. We consecutively included 303 cases in the study: open = 147 (48.5%), laparoscopic = 50 (16.5%), and robotic = 106 (35.0%). The median tumor size was significantly larger in the ODP group (P < 0.001) compared to the others. Cases in the RDP group experienced a longer duration of surgery (P < 0.001), smaller amount of blood loss (P < 0.001), smaller amount of blood transfusion (P = 0.042), and a shorter duration of hospital stay (p = 0.040) compared to cases in the ODP group. There was no significant difference observed when comparing other postoperative outcomes across the groups. Overall survival (OS) and progression-free survival (PFS) were similar across the significant differences among the three groups. The short-term postoperative and oncologic outcomes observed in the RDP and LDP groups were not inferior to those in the ODP group. The RDP has some perioperative advantages over the ODP. Therefore, RDP and LDP can safely and feasibly be performed in selected pancreatic tumors by experienced pancreatic surgeons.

Laparoscopic distal pancreatectomy for benign and malignant disease: a review of techniques and results.

Diagnosis of pancreatic cancer is challenging in the initial phases because its progression is rapid. The pancreatic tail and body roughly accounts for 20-30% of all cancerous cases. The standard treatment for symptomatic benign, malignant, and premalignant diseases of the pancreatic tail and body is distal pancreatectomy. This technique has been modified over the years to fit certain indications, with the goal of enhancing post-operative results as well as reducing patient trauma. In cases of a premalignant and symptomatic benign condition, the spleen must be preserved either using Kimura's splenic vessel preservation technique or Warshaw's splenic vessel resection technique. A better long-term prognosis is ensured by regional lymph node dissection and radical R0 resection. Radical antegrade modular pancreatosplenectomy was proposed to tackle the shortcomings of traditional surgery for pancreatic tail and body cancer. In this review, study techniques and results of laparoscopic distal pancreatectomy for malignant and benign pancreatic ailments were described with the intention of providing knowledge on various suitable techniques reported for pancreatic cancer treatment. Furthermore, this study will serve as a ready reckoner for surgeons and could serve to boost their confidence levels during surgery by avoiding confusion on the selection of suitable for the pancreatic diseases diagnosed.

Risk factors and consequences of conversion in minimally invasive distal pancreatectomy.

Background: Although recent studies have reported potential benefits of laparoscopic approach in distal pancreatectomy, reports of conversion during minimally invasive distal pancreatectomy (MIDP) were limited. Methods: This was a retrospective study using data from Sir Run Run Shaw Hospital around May 2013 to December 2018. Outcomes of patients who had conversions during MIDP were compared with patients with successful MIDP and with patients undergoing open distal pancreatectomy (ODP). Results: Two-hundred and eighty-three cases were included in this study: 225 (79.5%) had MIDP, 30 (10.6%) had conversions and 28 (9.9%) had outpatient department. The risk factors for conversion included large lesion size (heart rates [HR]: 5.632, 95% confidencevinterval [CI]: 1.036-1.450, P = 0.018) and pancreatic cancer (HR: 6.957, 95% CI: 1.359-8.022, P = 0.009). Compared with MIDP, those who required conversion were associated with longer operations (P = 0.003), higher blood loss (P < 0.001) and more severe of the complications (P < 0.001). However, no statistically significant differences were found between the conversion group and ODP. Conclusions: Large lesion size and pancreatic cancer were reported to be independent risk factors for conversion during MIDP. As for post-operative outcomes, the outcomes of successfully MIDP were better than those for conversion. However, conversion did not lead to worsening outcomes when compared with ODP.

Assessment of laparoscopic versus open distal pancreatectomy: a systematic review and meta-analysis.

BACKGROUND: The surgical benefits of open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) as a treatment for pancreatic disease in the body or tail were compared. MATERIAL AND METHODS: We searched PubMed, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and Web of Science from 1 August 1990 to 1 July 2019. Studies comparing total LDP and ODP were included. RESULTS: In total, we reviewed 30 studies covering 4040 subjects. The analysis displayed a similar incidence of CR-POPF and POPF between ODP and LDP groups. The findings indicate that LDP correlates with fewer total complications, lower estimated blood loss, shorter length of stay and shorter postoperative hospital stay. There was no significant difference in the operation time, R0 resection, postoperative hemorrhage, number of lymph nodes collected, reoperation, major complications, or mortality. CONCLUSIONS: Application of the International Study Group on Pancreatic Fistula (2017) criteria in this meta-analysis showed that LDP had surgical outcomes comparable with those of ODP. However, LDP has the benefits of causing a relatively lower estimated blood loss, a small number of total complications, and a shorter hospital stay. We, however, note that further high-quality and controlled trials are required to comprehensively compare these treatments.

Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma: a systematic review and meta-analysis.

OBJECTIVES: To compare the effectiveness, safety and oncologic adequacy of laparoscopic and open distal pancreatectomy (ODP) for pancreatic adenocarcinoma. METHODS: A systematic literature search was performed using EMBASE, Medline, the Cochrane library, and Google Scholar. Meta-analyses were performed using both fixed-effect and random-effect models. A cumulative meta-analysis was performed to track the accumulation of evidence. The power that a new trial of specified samples would give to the present meta-analysis was estimated with simulation-based sample size calculation. RESULTS: Patients who underwent laparoscopic distal pancreatectomy (LDP) had significantly smaller tumours [mean difference (MD) = -0.49 (-0.83 to -0.14), p = 0.005], less estimated blood loss [MD = -157.27 (-281.63 to -32.91), p = 0.01], and shorter average hospital stay by two days [MD = -2.35 (-3.1 to -1.59), p < .001] than those who underwent ODP. No significant differences in feasibility, effectiveness, and safety were noted. Cumulative meta-analysis demonstrated that the results were not dominated by a particular study. A new trial with 350 patients in each arm will give a maximum power of 48% to the present meta-analysis. CONCLUSIONS: LDP for pancreatic adenocarcinoma provides similar clinical and oncologic outcomes with shorter hospital stay by two days compared to ODP. However, underpowered sample size and smaller tumour size may have influenced the results of laparoscopic surgery. Therefore, an adequately powered randomized controlled trial is needed to shed further light on the appropriateness of this approach.

Laparoscopic distal pancreatectomy: which factors are related to open conversion? Lessons learned from 68 consecutive procedures in a high-volume pancreatic center.

BACKGROUND: Laparoscopic distal pancreatectomy represents a difficult surgical procedure with an high conversion rate to open procedure. The factors related to its difficulty and conversion to open distal pancreatectomy were rarely reported. The aim of the present study was to identify which factors are related to conversion from laparoscopic to open distal pancreatectomy. METHODS: A retrospective study of a prospective database of 68 patients who underwent laparoscopic distal pancreatectomy was conducted at a high-volume center by pancreatic surgeons experienced with laparoscopic surgery. Pre-intra and postoperative data were collected. Patients who completed a laparoscopic distal pancreatectomy were compared with those who needed a conversion to the open approach as regard demographic, clinical, radiological, and surgical data. Univariate and multivariate analyses were carried out. RESULTS: Univariate analysis suggested that the site of the lesion, the extension of pancreatic resection, and the requirement for an extended procedure to adjacent organs were significantly associated with the risk of conversion to the open approach. Multivariate analysis showed that only the extension of the pancreatic resection (subtotal pancreatectomy) was significantly related to the odds of conversion [odds ratio (OR) 19.5; 95% confidence interval (CI) 1.1-32.3; P = 0.038]. Preoperative suspicion of malignancy differed between the two groups; however, this difference did not reach statistical significance (P = 0.078). CONCLUSIONS: Despite the limitations of the study, only the extension of pancreatic resection seemed to be the main factor related to conversion during laparoscopic distal pancreatectomy.

[Comparison of laparoscopic distal pancreatectomy and open distal pancreatectomy in pancreatic ductal adenocarcinoma].

Objective: To compare and evaluate the curative effect of laparoscopic distal pancreatectomy(LDP) and traditional open distal pancreatectomy(ODP) in pancreatic ductal adenocarcinoma. Methods: The clinical data of 15 patients treated by LDP and 87 contemporaneous cases treated by ODP from January 2010 to November 2015 was collected, and the curative effect and prognosis of these patients were retrospectively analyzed. Results: The operation time of LDP group was (286.5±48.1) min, significantly longer than that of OPD group(226.6±56.8) min (P<0.05). The operative hemorrhage, postoperative exhaust time, recovery eating time, the whole and postoperative hospitalization time of LDP group were (188.7±108.9) ml, (2.2±1.3) d, (2.9±1.1) d, (13.2±10.4) d and (9.3±8.1) d, respectively, dramatically shorter than those of ODP group (625.2±982.1) ml, (4.3±1.7) d, (5.2±1.8) d, (20.7±8.7) d and (14.9±7.8) d, respectively (all of P<0.05). There were no intraoperative blood transfusion case in LDP group, however, 13 patients in ODP group received intraoperative blood transfusion, without significant difference (P=0.207). Alternatively, 6 cases occurred pancreatic fistula in LDP group, among them, 5 cases were grade A and 1 case was grade B; In ODP group, 17 cases occurred pancreatic fistula, among them 13 cases were grade A, 1 case was grade B and 3 cases were grade C, without significant differences (P=0.130). There were 2 cases of delayed gastric empty, 1 case of pulmonary infection in LDP group. In ODP group, there were 5 cases of postoperative delayed gastric empty, 3 cases of pulmonary infection and 6 cases of intra-abdominal infection, without significant differences (P>0.05). In both LDP group and ODP group, none occurred percutaneous drainage, re-admissions, second operation or perioperative death. Conclusions: Compared to ODP, LDP is much safer and more steady in perioperative periodand operation. Patients of pancreatic ductal adenocarcinoma received LDP can acquire more benefit and recovery sooner, and LDP is a safe and effective operative method.

Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center experience.

OBJECTIVE: The aim of this study was to compare complications and oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) at a single center. METHODS: Distal pancreatectomies performed for pancreatic ductal adenocarcinoma during a 4-year period were included in this study. A retrospective analysis of a database of this cohort was conducted. RESULTS: Twenty-two patients underwent LDP for pancreatic ductal adenocarcinoma, in comparison to seventy-six patients with comparable tumor characteristics treated by ODP. No patients with locally advanced lesions were included in this study. Comparing LDP group to ODP group, there were no significant differences in operation time (P=0.06) or blood loss (P=0.24). Complications (pancreatic fistula, P=0.62; intra-abdominal abscess, P=0.44; postpancreatectomy hemorrhage, P=0.34) were similar. There were no significant differences in the number of lymph nodes harvested (11.2±4.6 in LDP group vs. 14.4±5.5 in ODP group, P=0.44) nor the rate of patients with positive lymph nodes (36% in LDP group vs. 41% in ODP group, P=0.71). Incidence of positive margins was similar (9% in LDP group vs. 13% in ODP group, P=0.61). The mean overall survival time was (29.6±3.7) months for the LDP group and (27.6±2.1) months for ODP group. There was no difference in overall survival between the two groups (P=0.34). CONCLUSIONS: LDP is a safe and effective treatment for selected patients with pancreatic ductal adenocarcinoma. A slow-compression of pancreas tissue with the GIA stapler is effective in preventing postoperative pancreatic fistula. The oncologic outcome is comparable with the conventional open approach. Laparoscopic radical antegrade modular pancreatosplenectomy contributed to oncological clearance.

Laparoscopic versus open distal pancreatectomy-a propensity score-matched analysis from the German StuDoQ|Pancreas registry.

PURPOSE: The aim of this study was to assess intraoperative, postoperative, and oncologic outcome in patients undergoing laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) for benign and malignant lesions of the pancreas. METHODS: Data from patients undergoing distal pancreatic resection were extracted from the StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery. After propensity score case matching, groups of LDP and ODP were compared regarding demography, comorbidities, operative details, histopathology, and perioperative outcome. RESULTS: At the time of data extraction, the StuDoQ|Pancreas registry included over 3000 pancreatic resections from over 50 surgical departments in Germany. Data from 353 patients undergoing ODP (n = 254) or LDP (n = 99) from September 2013 to February 2016 at 29 institutions were included in the analysis. Baseline data showed a strong selection bias in LDP patients, which disappeared after 1:1 propensity score matching. A comparison of the matched groups disclosed a significantly longer operation time, higher rate of spleen preservation, more grade A pancreatic fistula, shorter hospital stay, and increased readmissions for LDP. In the small group of patients operated for pancreatic cancer, a lower lymph node yield with a lower lymph node ratio was apparent in LDP. CONCLUSIONS: LDP needed more time but potential advantages include increased spleen preservation and shorter hospital stay, as well as a trend for less transfusion, ventilation, and mortality. LDP for pancreatic cancer was performed rarely and will need critical evaluation in the future. Data from a prospective randomized registry trial is needed to confirm these results.

Comparison of laparoscopic distal pancreatectomy and open distal pancreatectomy in pancreatic ductal adenocarcinoma / 中华肿瘤杂志

Objective@#To compare and evaluate the curative effect of laparoscopic distal pancreatectomy(LDP) and traditional open distal pancreatectomy(ODP) in pancreatic ductal adenocarcinoma.@*Methods@#The clinical data of 15 patients treated by LDP and 87 contemporaneous cases treated by ODP from January 2010 to November 2015 was collected, and the curative effect and prognosis of these patients were retrospectively analyzed.@*Results@#The operation time of LDP group was (286.5±48.1) min, significantly longer than that of OPD group(226.6±56.8) min (P<0.05). The operative hemorrhage, postoperative exhaust time, recovery eating time, the whole and postoperative hospitalization time of LDP group were (188.7±108.9) ml, (2.2±1.3) d, (2.9±1.1) d, (13.2±10.4) d and (9.3±8.1) d, respectively, dramatically shorter than those of ODP group (625.2±982.1) ml, (4.3±1.7) d, (5.2±1.8) d, (20.7±8.7) d and (14.9±7.8) d, respectively (all of P<0.05). There were no intraoperative blood transfusion case in LDP group, however, 13 patients in ODP group received intraoperative blood transfusion, without significant difference (P=0.207). Alternatively, 6 cases occurred pancreatic fistula in LDP group, among them, 5 cases were grade A and 1 case was grade B; In ODP group, 17 cases occurred pancreatic fistula, among them 13 cases were grade A, 1 case was grade B and 3 cases were grade C, without significant differences (P=0.130). There were 2 cases of delayed gastric empty, 1 case of pulmonary infection in LDP group. In ODP group, there were 5 cases of postoperative delayed gastric empty, 3 cases of pulmonary infection and 6 cases of intra-abdominal infection, without significant differences (P>0.05). In both LDP group and ODP group, none occurred percutaneous drainage, re-admissions, second operation or perioperative death.@*Conclusions@#Compared to ODP, LDP is much safer and more steady in perioperative periodand operation. Patients of pancreatic ductal adenocarcinoma received LDP can acquire more benefit and recovery sooner, and LDP is a safe and effective operative method.

Comparative study of laparoscopic and open distal pancreatectomy / 第二军医大学学报

Objective To assess the feasibility, safety and efficacy of laparoscopic distal pancreatectomy (LDP) by comparing LDP with open distal pancreatectomy (ODP). Methods The clinical data of 68 patients with pancreatic body or tail diseases, who received distal pancreatectomy from May 2011 to February 2012, were retrospectively analyzed. LDP was performed in 16 cases and ODP in 52 cases. The baseline clinical data and the intraoperative and postoperative findings were compared between the two groups. Results There was no death in the two groups. The sex ratio, age, body mass index,tumor diameter and total hospital costs were not significantly different between the two groups. The incision length of LDP group was significantly shorter than that of ODP group (\[3.50±1.34\] cm vs \[17.94±2.12\] cm, P<0.001). The operative duration of LDP group was significantly longer than that of ODP group (\[145.63±56.80\] min vs \[87.21±32.06\] min,P<0.001). Postoperative hospital stay of LDP and ODP groups were (5.06±1.24) d and (8.06±2.53) d (P<0.001), time in bed after surgery were (1.31±0.68) d and (2.94±0.80) d (P<0.001), and postoperative fasting time were (1.31±0.57) d and (2.86±1.34) d (P<0.001), respectively. Estimated blood loss of LDP and ODP groups were (318.75±227.21) ml and (306.35±378.36) ml (P=0.898), respectively. Four patients had pancreatic leakages and 1 had peritoneal effusion in LDP group. Twelve patients had pancreatic leakages and 3 had peritoneal effusions in ODP group, with one having both pancreatic leakage and peritoneal effusion. There were no significant differences in the incidence of pancreatic leakage and peritoneal effusion between the two groups. The postoperative pain score was mainly 1-2 in LDP group and 2-3 in ODP group, with significant differences found between the two groups (P<0.001). Conclusion LDP is feasible and safe in treating benign or borderline disease of pancreatic body and tail. Compared to ODP,LDP has the advantage of less trauma and pain, quicker recovery without increasing the total costs.