- Email: [email protected]
Minimally invasive pancreaticoduodenectomy – A review
CMRP-150; No. of Pages 5 current medicine research and practice xxx (2016) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Review Article
Minimally invasive pancreaticoduodenectomy – A review Neeraj Dhamija, Kumar Manish, Brij B. Agarwal * Department of Laparoscopic & General Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
article info
abstract
Article history:
Pancreaticoduodenectomy (PD) is considered as a complex procedure and there have been
Received 29 December 2015
exciting developments over some advancement in the field of minimally invasive pancreatic
Accepted 13 January 2016
surgery (MIPS) over the last decade. But MIPS has not progressed much due to surgical
Available online xxx
reluctance as well as technical challenges. Improvement in the technology and instrumen-
Keywords:
trained in advanced laparoscopic procedures, to adapt to this approach in performing PD
tation in minimally invasive approach (laparoscopic and robotic) has made the surgeons, Pancreaticoduodenectomy
with acceptable oncological outcomes. A high mortality and morbidity rate associated with
Minimally invasive pancreatic
PD is of concern. This review addresses various important factors associated with minimally
surgery
invasive PD, its feasibility, and outcomes.
Robotic pancreatic surgery
# 2016 Sir Ganga Ram Hospital. Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd. All rights reserved.
1.
Introduction
Over the last 3 decades, minimally invasive surgery (MIS) has seen a lot of advancement both in terms of technology and in performing complex abdominal surgeries. With evolution of proficiency curve, MIS is seen as a tool to reproduce the wisdom of conventional era. Laparoscopic and robotic surgeries, both tools of MIS, are now considered to be the preferred modality for many such surgeries. The benefit of the MIS is not just cosmetic. Many studies have shown a decrease in the inflammatory response and less postoperative immunosuppression, which translates into potential oncological benefits.1,2 The MIS also offers a magnified view that aids in the meticulous precise dissection and access to the areas, which are relatively inaccessible and difficult to reach by any open technique. The MIS has already established its superiority
in terms of the enhanced recovery of the patient with improved wound related morbidities. Despite of all the technological advancements in the MIS and increasing experience with such techniques, the MIS of the pancreas is still in its infancy. There are various factors, which are responsible for this slow acceptance of MIS approach for pancreatic surgeries. The close proximity of the pancreas to major vascular structures, difficult and unforgiving tissue characteristics, and complex reconstruction procedures are main factors, because of which pancreatic surgery is considered to be the 'TigerTerritory' for the surgeon. Soper et al. first described MIS for the pancreas in a porcine model in the mid 1990s.3,4 Following this, in 1997, a trial of 11 patients undergoing laparoscopic pancreaticoduodenectomy (PD) was published, demonstrating the feasibility of the procedure without increase in the mortality.5 Despite these feasibility studies, the only widespread use of MIS for
* Corresponding author. Tel.: +91 9810124256. E-mail address: [email protected] (B.B. Agarwal). http://dx.doi.org/10.1016/j.cmrp.2016.01.002 2352-0817/# 2016 Sir Ganga Ram Hospital. Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd. All rights reserved.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5
2
current medicine research and practice xxx (2016) xxx–xxx
the pancreas was for diagnostic or staging purpose and to perform palliative procedures in advance pancreatic malignancies.6,7 Until a decade ago there were no large series reports published for MIS of the pancreas, which were mostly laparoscopic distal pancreatectomy.8 Larger series reporting outcomes compared to open distal pancreatectomy soon followed,9–13 allowing for meta-analysis and large population based studies, which demonstrated the benefit of minimally invasive pancreatic surgery (MIPS).14–16 Several reports regarding the feasibility of the robotic17–19 and laparoscopic20–23 proximal pancreatic resections have been published, but these reports are limited to select centers and surgeons. The aim of this review is to provide the reader with an update on the current status of the minimally invasive PD. There are many key questions, which come into the mind of surgeons, when we think of MIPS. We have divided the review into ten headings, so that we can focus on various issues individually.
2. Acceptance of the minimally invasive approach for the pancreas Unlike most other solid organ or visceral procedures, the acceptance of the MIPS was significantly delayed. This was mainly because of the doubts in the mind of the HPB surgeons for successful completion of these complex procedures. The improvements in the surgical instrumentation and technology boosted the innovative surgeons to perform such complex procedures as they naturally concluded that MIPS would benefit patients in the same manner as it does for other indications. Despite of the initial hurdles, some dedicated surgeons persisted to push past the initial learning curve.20 Advancements in the pancreatic imaging in terms of better localization of the pancreatic tumor and determination of its vascular relations and contiguous organ involvement also made the preoperative selections of the patients for minimally invasive approach, improvement of its outcome, and thus acceptability of this approach. This information also led to the decreased need of the surgeon to manual palpation of the tumor before proceeding for resection. All these factors led to increased acceptability of MIPS.
3. PD?
Is the concept of fast recovery holds true in
The concept of fast recovery is more or less synonymous with the MIS in the mindset of a lot of patients and even surgeons. While this concept has not been defined specifically for the patients undergoing complex pancreatic surgeries. In such surgeries, the faster recovery cannot be measured by pain scales, return to work or even length of stay in the hospital, as theses are affected by multitude of other factors associated with the recovery from a complex procedure. So the incision for the access into the abdominal cavity is not likely to be as clinically relevant as for less complex minimally invasive procedures. The benefit in regard to improvements in quality of life, less morbidity, long-term functional squeal, and overall benefit is more important than fast recovery.
4.
Impact on the morbidity and mortality
A realistic appraisal of the current PD outcome, even at highvolume centres24 indicates an operative mortality rate between 2% and 5% with morbidity in 40–50% of the patients.25,26 Recent International Study Group consensus guidelines that define pancreatic fistula (PF),27 delayed gastric emptying,28 and post-pancreatectomy hemorrhage29 as well as standard grading system for complications after pancreatic surgery30 allow us to compare complications in more objective manner. Comparative studies between laparoscopic22 and robotic17,18 PD vs open PD have shown no significant differences in major complications, mortality or PF rates between two approaches. There are only large case series reports regarding minimally invasive PD from small numbers of high volume institutions with case numbers ranging from 62 to 132 patients available.18,19,21,31 These noncomparison studies report outcomes that are consistent with results expected from high volume institutes with experienced surgeons. Major morbidity and mortality rates range from 25% to 42% and 1% to 3.8%, respectively. PF and wound infection ranged from 6.7% to 27% and 1% to 6%, respectively.
4.1.
Blood loss and transfusion
Intra operative blood loss and the subsequent use of red blood cell transfusions recently have been identified as a significant determination on overall patient survival in the setting of malignancy in multiple studies.32,33 In PD, the estimated operative blood loss has been clearly shown to be significantly decreased with the use of laparoscopic (195 ml vs 1032 ml)22 and robotic (387 ml vs 827 ml)18 approaches. One of the factors responsible for the less blood loss in minimally invasive PD is that it requires very precise technique and relatively bloodless planes of dissection in comparison to open technique.
5.
Operative time
Operative time for performing PD by any technique is usually not considered to be of any importance in the mindset of surgical fraternity as far as the outcome after PD is concerned. The operative time in performing such complex surgeries is of importance only as a metric of resource utilization. The operative time for open PD has remained stable over the years and has reached a plateau. Minimally invasive PD, in contrast, always has been associated with significantly longer operative time when compared to open technique.17,22,28 Kim et al.23 described a reduction in the operative time from 9.8 h to 7.9 h to 6.6 h for his series of 100 minimally invasive PD over the course of three equal time periods within the study. Kendrick and Cusati21 reported a decrease from 7.7 h for their first 10 patients to 5.3 h for their last 10 patients of the study. Zureikat et al.31 showed a study and significant drop in the operative time of >200 min over a course of 132 PDs. Whether or not this variable impacts patients outcome but the operative time will reduce considerably as experience is gained.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5 current medicine research and practice xxx (2016) xxx–xxx
6.
Conversion to open technique
Conversion of the MIPS to open does not lose all the advantages of the MIS and should not be considered as the failure of procedure. Especially in an obese patient, there are certain steps, which are done with significant ease with minimally invasive approach like mobilization of the hepatic flexor of the colon. Many times, there is a variable amount of inflammatory, desmoplastic or fibrotic changes around the diseased pancreas, which is usually difficult to assess by radio imaging. Many surgeons are now advocating the hybrid technique for performing PD, where dissection is performed through minimally invasive approach, and reconstruction is done by making a small incision.34,35 Minimally invasive PD has been reported to have a 5–15% conversion rate, but these conversions were either not included in the analysis21,23 or were considered as a part of the open subgroup.22
7.
Oncological outcomes
Minimally invasive pancreatic resections are commonly performed for pancreatic malignancy.36 Oncological outcome of any minimally invasive approach is of concern. In a study at Mayo clinic, Florida, comparing resected specimen of laparoscopic vs open PD found out that the laparoscopic approach was associated with significantly higher lymph node harvest (23 vs 17, p = 0.001).22 For patients with a positive node status high yield of lymph node is having a direct impact on the oncological outcome and a confirmed predictor of survival for pancreatic adenocarcinoma.37,38 High yield of lymph nodes during MIPS can be attributed to the magnification of vision, greater access to the regions that are difficult to reach by open technique including the retropancreatic and superior mesenteric lymph nodes. The resection of the carcinoma of Rectum, 'Total Mesorectal Excision' is described to be the preferred plane of dissection as per oncologic principles; similarly, for pancreatic resection, a 'Mesopancreatic plane' has been described and is postulated to be of oncologic relevance with an en-bloc resection of the pancreas with surrounding layers of fat.43 Many large series have reported high rates of margin-negative resections for minimally invasive PD.18,21–23 Chalikonda et al.17 reported significantly higher R0 resection rate for robotic PD over open procedure. MIS also offers advantages such as 'no-touch' surgical approach for tumors of the pancreas.39 Minimally invasive PD is also associated with a shorter time to initiate adjuvant chemotherapy or radiotherapy after PD.40 Shoup et al.36 reported recurrence and survival data at 2 years of 38% vs 32% and 43% vs 36% comparing MIS and open approach for pancreatic resections.
8.
Cost considerations
This issue is multifactorial. The cost of instruments and consumables used in robotic and laparoscopic approaches may be higher as compared to the open approach, but use of
3
intensive care, length of stay in hospital, and operative time differences are other factors that affect cost of such complex surgery. An analysis of the overall admission costs of a patient, who underwent PD at Mayo clinic in Florida confirms that even early during the adoption phase, the minimally invasive approach is not associated with increased costs.41 The two factors responsible for the compensation of the high cost of the equipment and consumable for the surgery are the shorter hospital stay and lower morbidity.
9.
Is MIS always indicated?
Indications of MIS are increasing, and as discussed, more and more complex open surgical procedures are now being performed by using a minimally invasive approach. Should all the patients are eligible candidates for MIPS? Most of the surgeons, who begin performing MIPS would agree that patient selection is absolutely necessary for the initial patients. The key factors making a patient suitable for the MIS surgery are the straightforward anatomy, non-complex lesions, and patient on the average or lower side for BMI. Patient selection is having a direct impact on the overall success of the MIS. Relative contraindications for the MIPS are patients with previous upper abdominal surgeries such as complex gastric and biliary procedures, and patients with chronic pancreatitis. These conditions make difficult anatomical planes for dissection leading to high risk of damage to vital vascular structures and conversion/complication rates. Large bulky tumors that make manipulations difficult and significant vascular involvement are other factors that make the dissection difficult even for the experienced surgeons. Kendrick et al.42 reported the feasibility of vascular resections by laparoscopic approach for PD further expanding the horizon for MIS. Baumgartner et al.43 recently reported the ability to perform arterial resection during robotic PD. Neoadjuvant radiotherapy and chemotherapy further make the anatomical planes difficult to dissect and may be relative contraindication for MIPS.
10.
Training and learning curves
MIS for PD requires extensive training and is associated with longer learning curves. This is mainly based on the fact that traditionally pancreatic surgery is performed by using an open technique, to which the pancreatic surgeons are familiar with. The present era is different, wherein surgical trainees are taught the basic laparoscopic techniques during their postgraduate training. This leads to the development of the mindset of a minimally invasive surgeon, and it is these surgeons, who have a shorter learning curve for performing any new minimally invasive procedure. The video recording of the minimally invasive procedures further shortens the learning curve for a particular procedure. The technique of laparoscopic resection has led to several modifications of the open surgical steps because of greater understanding of the tissue planes, anatomy, dissection method, and instrumentation.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5
4
current medicine research and practice xxx (2016) xxx–xxx
11.
Conclusion
Minimally invasive PD is a feasible option in the hands of experienced laparoscopic and robotic surgeon. Proper patient selection is necessary especially during the early phase for successful completion of minimally invasive procedure. Both laparoscopic and robotic PDs have shown good results in recent reports with oncological safety. Mere presence of a robot at the institution should not be the driving force to do minimally invasive PD. The surgeons should go through a well-designed training process as strong as for surgeon, who performs a traditional open PD. For those surgeons, who have extensive experience in performing minimally invasive pancreatic resections, it has become evident that minimally invasive approach has served to improve the open pancreatic resections by applying what we have learned from the minimally invasive approach. MIPS is going to stay. Further studies are needed to compare the advantages of this approach over the traditional open PD prior to stating that it should be considered the approach of choice.
Conflicts of interest The authors have none to declare.
references
1. Carter JJ, Whelan RL. The immunologic consequences of laparoscopy in oncology. Surg Oncol Clin North Am. 2001;10:655–677. 2. Trokel MJ, Bessler M, Treat MR, et al. Preservation of immune response after laparoscopy. Surg Endosc. 1994;8:1385–1387. 3. Soper NJ, Brunt LM, Dunnegan DL, et al. Laparoscopic distal pancreatectomy in the porcine model. Surg Endosc. 1994;8:57–60. 4. Jones DB, Wu JS, Soper NJ. Laparoscopic pancreaticoduodenectomy in the porcine model. Surg Endosc. 1997;11:326–330. 5. Gagner M, Pomp A. Laparoscopic pancreatic resection: is it worthwhile? J Gastrointest Surg. 1997;1:20–25. 6. Pisters PW, Lee JE, Vauthey JN, et al. Laparoscopy in the staging of pancreatic cancer. Br J Surg. 2001;88:325–337. 7. Barabino M, Santambrogio R, Pisani Ceretti A, et al. Is there still a role for laparoscopy combined with laparoscopic ultrasonography in the staging of pancreatic cancer? Surg Endosc. 2011;25:160–165. 8. Ammori BJ, Baghdadi S. Minimally invasive pancreatic surgery: the new frontier? Curr Gastroenterol Rep. 2006;8:132–142. 9. Stauffer JA, Rosales-Velderrain A, Goldberg RF, et al. Comparison of open with laparoscopic distal pancreatectomy: a single institution's transition over a 7year period. HPB. 2013;15:149–155. 10. Kim SC, Park KT, Hwang JW, et al. Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution. Surg Endosc. 2008;22:2261–2268. 11. DiNorcia J, Schrope BA, Lee MK, et al. Laparoscopic distal pancreatectomy offers shorter hospital stays with fewer complications. J Gastrointest Surg. 2010;14:1804–1812.
12. Vijan SS, Ahmed KA, Harmsen WS, et al. Laparoscopic open distal pancreatectomy: a single-institution comparative study. Arch Surg. 2010;145:616–621. 13. Jayaraman S, Gonen M, Brennan MF, et al. Laparoscopic distal pancreatectomy: evolution of a technique at a single institution. J Am Coll Surg. 2010;211:503–509. 14. Jin T, Altaf K, Xiong JJ, et al. A systematic review and metaanalysis of studies comparing laparoscopic and open distal pancreatectomy. HPB. 2012;14:711–724. 15. Venkat R, Edil BH, Schulick RD, et al. Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis. Ann Surg. 2012;255:1048–1059. 16. Tran Cao HS, Lopez N, Chang DC, et al. Improved perioperative outcomes with minimally invasive distal pancreatectomy: results from a population-based analysis. JAMA. 2014;149:237–243. 17. Chalikonda S, Aguilar-Saavedra JR, Walsh RM. Laparoscopic robotic-assisted pancreaticoduodenectomy: a case-matched comparison with open resection. Surg Endosc. 2012;26: 2397–2402. 18. Buchs NC, Addeo P, Bianco FM, et al. Robotic versus open pancreaticoduodenectomy: a comparative study at a single institution. World J Surg. 2011;35:2739–2746. 19. Zeh HJ, Zureikat AH, Secrest A, et al. Outcomes after robotassisted pancreaticoduodenectomy for periampullary lesions. Ann Surg Oncol. 2012;19:864–870. 20. Palanivelu C, Jani K, Senthilnathan P, et al. Laparoscopic pancreaticoduodenectomy: technique and outcomes. J Am Coll Surg. 2007;205:222–230. 21. Kendrick ML, Cusati D. Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience. Arch Surg. 2010;145:19–23. 22. Asbun HJ, Stauffer JA. Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System. J Am Coll Surg. 2012;215:810–819. 23. Kim SC, Song KB, Jung YS, et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pyloruspreserving pancreatoduodenectomy: improvement with surgical experience. Surg Endosc. 2013;27:95–103. 24. Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticodudenectomy. Ann Surg. 2003;237:509–514. 25. Cuschieri A, Jakimowicz JJ, van Spreeuwel J. Laparoscopic distal 70% pancreatectomy and splenectomy for chronic pancreatitis. Ann Surg. 1996;223:280–285. 26. Gagner M, Pomp A, Herrera MF. Early experience with laparoscopic resections of islet cell tumors. Surgery. 1996;120:1051–1054. 27. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13. 28. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142:761–768. 29. Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142: 20–25. 30. DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg. 2006;244:931–937. 31. Zureikat AH, Moser AJ, Boone BA, et al. 250 robotic pancreatic resections: safety and feasibility. Ann Surg. 2013;258:554–559.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5 current medicine research and practice xxx (2016) xxx–xxx
32. Nagai S, Fujii T, Kodera Y, et al. Impact of operative blood loss on survival in invasive ductal adenocarcinoma of the pancreas. Pancreas. 2011;40:3–9. 33. Kneuertz PJ, Patel SH, Chu CK, et al. Effects of perioperative red blood cell transfusion on disease recurrence and survival after pancreaticoduodenectomy for ductal adenocarcinoma. Ann Surg Oncol. 2011;18:1327–1334. 34. Kuroki T, Adachi T, Okamoto T, et al. A non-randomized comparative study of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy. Hepatogastroenterology. 2012;59:570–573. 35. Lee JS, Han JH, Na GH, et al. Laparoscopic pancreaticoduodenectomy assisted by mini-laparotomy. Surg Laparosc Endosc Percutan Tech. 2013;23:e98–e102. 36. Shoup M, Brennan MF, McWhite K, et al. The value of splenic preservation with distal pancreatectomy. Arch Surg. 2002;137:164–168. 37. Pawlik TM, Gleisner AL, Cameron JL, et al. Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer. Surgery. 2007;141:610–618.
38. Huebner M, Kendrick M, Reid-Lombardo KM, et al. Number of lymph nodes evaluated: prognostic value in pancreatic adenocarcinoma. J Gastrointest Surg. 2012;16:920–926. 39. Hirota M, Shimada S, Yamamoto K, et al. Pancreatectomy using the no-touch isolation technique followed by extensive intraoperative peritoneal lavage to prevent cancer cell dissemination: a pilot study. JOP. 2005;6:143–151. 40. Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches? Ann Surg. 2014;260(4):633–638. 41. Mesleh MG, Stauffer JA, Bowers SP, et al. Cost analysis of open and laparoscopic pancreaticoduodenectomy: a single institution comparison. Surg Endosc. 2013;27:4518–4523. 42. Kendrick ML, Sclabas GM. Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB. 2011;13:454–458. 43. Baumgartner JM, Krasinskas A, Daouadi M, et al. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy. J Gastrointest Surg. 2012;16:1152–1159.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Review Article
Minimally invasive pancreaticoduodenectomy – A review Neeraj Dhamija, Kumar Manish, Brij B. Agarwal * Department of Laparoscopic & General Surgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110060, India
article info
abstract
Article history:
Pancreaticoduodenectomy (PD) is considered as a complex procedure and there have been
Received 29 December 2015
exciting developments over some advancement in the field of minimally invasive pancreatic
Accepted 13 January 2016
surgery (MIPS) over the last decade. But MIPS has not progressed much due to surgical
Available online xxx
reluctance as well as technical challenges. Improvement in the technology and instrumen-
Keywords:
trained in advanced laparoscopic procedures, to adapt to this approach in performing PD
tation in minimally invasive approach (laparoscopic and robotic) has made the surgeons, Pancreaticoduodenectomy
with acceptable oncological outcomes. A high mortality and morbidity rate associated with
Minimally invasive pancreatic
PD is of concern. This review addresses various important factors associated with minimally
surgery
invasive PD, its feasibility, and outcomes.
Robotic pancreatic surgery
# 2016 Sir Ganga Ram Hospital. Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd. All rights reserved.
1.
Introduction
Over the last 3 decades, minimally invasive surgery (MIS) has seen a lot of advancement both in terms of technology and in performing complex abdominal surgeries. With evolution of proficiency curve, MIS is seen as a tool to reproduce the wisdom of conventional era. Laparoscopic and robotic surgeries, both tools of MIS, are now considered to be the preferred modality for many such surgeries. The benefit of the MIS is not just cosmetic. Many studies have shown a decrease in the inflammatory response and less postoperative immunosuppression, which translates into potential oncological benefits.1,2 The MIS also offers a magnified view that aids in the meticulous precise dissection and access to the areas, which are relatively inaccessible and difficult to reach by any open technique. The MIS has already established its superiority
in terms of the enhanced recovery of the patient with improved wound related morbidities. Despite of all the technological advancements in the MIS and increasing experience with such techniques, the MIS of the pancreas is still in its infancy. There are various factors, which are responsible for this slow acceptance of MIS approach for pancreatic surgeries. The close proximity of the pancreas to major vascular structures, difficult and unforgiving tissue characteristics, and complex reconstruction procedures are main factors, because of which pancreatic surgery is considered to be the 'TigerTerritory' for the surgeon. Soper et al. first described MIS for the pancreas in a porcine model in the mid 1990s.3,4 Following this, in 1997, a trial of 11 patients undergoing laparoscopic pancreaticoduodenectomy (PD) was published, demonstrating the feasibility of the procedure without increase in the mortality.5 Despite these feasibility studies, the only widespread use of MIS for
* Corresponding author. Tel.: +91 9810124256. E-mail address: [email protected] (B.B. Agarwal). http://dx.doi.org/10.1016/j.cmrp.2016.01.002 2352-0817/# 2016 Sir Ganga Ram Hospital. Published by Elsevier, a division of Reed Elsevier India, Pvt. Ltd. All rights reserved.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5
2
current medicine research and practice xxx (2016) xxx–xxx
the pancreas was for diagnostic or staging purpose and to perform palliative procedures in advance pancreatic malignancies.6,7 Until a decade ago there were no large series reports published for MIS of the pancreas, which were mostly laparoscopic distal pancreatectomy.8 Larger series reporting outcomes compared to open distal pancreatectomy soon followed,9–13 allowing for meta-analysis and large population based studies, which demonstrated the benefit of minimally invasive pancreatic surgery (MIPS).14–16 Several reports regarding the feasibility of the robotic17–19 and laparoscopic20–23 proximal pancreatic resections have been published, but these reports are limited to select centers and surgeons. The aim of this review is to provide the reader with an update on the current status of the minimally invasive PD. There are many key questions, which come into the mind of surgeons, when we think of MIPS. We have divided the review into ten headings, so that we can focus on various issues individually.
2. Acceptance of the minimally invasive approach for the pancreas Unlike most other solid organ or visceral procedures, the acceptance of the MIPS was significantly delayed. This was mainly because of the doubts in the mind of the HPB surgeons for successful completion of these complex procedures. The improvements in the surgical instrumentation and technology boosted the innovative surgeons to perform such complex procedures as they naturally concluded that MIPS would benefit patients in the same manner as it does for other indications. Despite of the initial hurdles, some dedicated surgeons persisted to push past the initial learning curve.20 Advancements in the pancreatic imaging in terms of better localization of the pancreatic tumor and determination of its vascular relations and contiguous organ involvement also made the preoperative selections of the patients for minimally invasive approach, improvement of its outcome, and thus acceptability of this approach. This information also led to the decreased need of the surgeon to manual palpation of the tumor before proceeding for resection. All these factors led to increased acceptability of MIPS.
3. PD?
Is the concept of fast recovery holds true in
The concept of fast recovery is more or less synonymous with the MIS in the mindset of a lot of patients and even surgeons. While this concept has not been defined specifically for the patients undergoing complex pancreatic surgeries. In such surgeries, the faster recovery cannot be measured by pain scales, return to work or even length of stay in the hospital, as theses are affected by multitude of other factors associated with the recovery from a complex procedure. So the incision for the access into the abdominal cavity is not likely to be as clinically relevant as for less complex minimally invasive procedures. The benefit in regard to improvements in quality of life, less morbidity, long-term functional squeal, and overall benefit is more important than fast recovery.
4.
Impact on the morbidity and mortality
A realistic appraisal of the current PD outcome, even at highvolume centres24 indicates an operative mortality rate between 2% and 5% with morbidity in 40–50% of the patients.25,26 Recent International Study Group consensus guidelines that define pancreatic fistula (PF),27 delayed gastric emptying,28 and post-pancreatectomy hemorrhage29 as well as standard grading system for complications after pancreatic surgery30 allow us to compare complications in more objective manner. Comparative studies between laparoscopic22 and robotic17,18 PD vs open PD have shown no significant differences in major complications, mortality or PF rates between two approaches. There are only large case series reports regarding minimally invasive PD from small numbers of high volume institutions with case numbers ranging from 62 to 132 patients available.18,19,21,31 These noncomparison studies report outcomes that are consistent with results expected from high volume institutes with experienced surgeons. Major morbidity and mortality rates range from 25% to 42% and 1% to 3.8%, respectively. PF and wound infection ranged from 6.7% to 27% and 1% to 6%, respectively.
4.1.
Blood loss and transfusion
Intra operative blood loss and the subsequent use of red blood cell transfusions recently have been identified as a significant determination on overall patient survival in the setting of malignancy in multiple studies.32,33 In PD, the estimated operative blood loss has been clearly shown to be significantly decreased with the use of laparoscopic (195 ml vs 1032 ml)22 and robotic (387 ml vs 827 ml)18 approaches. One of the factors responsible for the less blood loss in minimally invasive PD is that it requires very precise technique and relatively bloodless planes of dissection in comparison to open technique.
5.
Operative time
Operative time for performing PD by any technique is usually not considered to be of any importance in the mindset of surgical fraternity as far as the outcome after PD is concerned. The operative time in performing such complex surgeries is of importance only as a metric of resource utilization. The operative time for open PD has remained stable over the years and has reached a plateau. Minimally invasive PD, in contrast, always has been associated with significantly longer operative time when compared to open technique.17,22,28 Kim et al.23 described a reduction in the operative time from 9.8 h to 7.9 h to 6.6 h for his series of 100 minimally invasive PD over the course of three equal time periods within the study. Kendrick and Cusati21 reported a decrease from 7.7 h for their first 10 patients to 5.3 h for their last 10 patients of the study. Zureikat et al.31 showed a study and significant drop in the operative time of >200 min over a course of 132 PDs. Whether or not this variable impacts patients outcome but the operative time will reduce considerably as experience is gained.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
CMRP-150; No. of Pages 5 current medicine research and practice xxx (2016) xxx–xxx
6.
Conversion to open technique
Conversion of the MIPS to open does not lose all the advantages of the MIS and should not be considered as the failure of procedure. Especially in an obese patient, there are certain steps, which are done with significant ease with minimally invasive approach like mobilization of the hepatic flexor of the colon. Many times, there is a variable amount of inflammatory, desmoplastic or fibrotic changes around the diseased pancreas, which is usually difficult to assess by radio imaging. Many surgeons are now advocating the hybrid technique for performing PD, where dissection is performed through minimally invasive approach, and reconstruction is done by making a small incision.34,35 Minimally invasive PD has been reported to have a 5–15% conversion rate, but these conversions were either not included in the analysis21,23 or were considered as a part of the open subgroup.22
7.
Oncological outcomes
Minimally invasive pancreatic resections are commonly performed for pancreatic malignancy.36 Oncological outcome of any minimally invasive approach is of concern. In a study at Mayo clinic, Florida, comparing resected specimen of laparoscopic vs open PD found out that the laparoscopic approach was associated with significantly higher lymph node harvest (23 vs 17, p = 0.001).22 For patients with a positive node status high yield of lymph node is having a direct impact on the oncological outcome and a confirmed predictor of survival for pancreatic adenocarcinoma.37,38 High yield of lymph nodes during MIPS can be attributed to the magnification of vision, greater access to the regions that are difficult to reach by open technique including the retropancreatic and superior mesenteric lymph nodes. The resection of the carcinoma of Rectum, 'Total Mesorectal Excision' is described to be the preferred plane of dissection as per oncologic principles; similarly, for pancreatic resection, a 'Mesopancreatic plane' has been described and is postulated to be of oncologic relevance with an en-bloc resection of the pancreas with surrounding layers of fat.43 Many large series have reported high rates of margin-negative resections for minimally invasive PD.18,21–23 Chalikonda et al.17 reported significantly higher R0 resection rate for robotic PD over open procedure. MIS also offers advantages such as 'no-touch' surgical approach for tumors of the pancreas.39 Minimally invasive PD is also associated with a shorter time to initiate adjuvant chemotherapy or radiotherapy after PD.40 Shoup et al.36 reported recurrence and survival data at 2 years of 38% vs 32% and 43% vs 36% comparing MIS and open approach for pancreatic resections.
8.
Cost considerations
This issue is multifactorial. The cost of instruments and consumables used in robotic and laparoscopic approaches may be higher as compared to the open approach, but use of
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intensive care, length of stay in hospital, and operative time differences are other factors that affect cost of such complex surgery. An analysis of the overall admission costs of a patient, who underwent PD at Mayo clinic in Florida confirms that even early during the adoption phase, the minimally invasive approach is not associated with increased costs.41 The two factors responsible for the compensation of the high cost of the equipment and consumable for the surgery are the shorter hospital stay and lower morbidity.
9.
Is MIS always indicated?
Indications of MIS are increasing, and as discussed, more and more complex open surgical procedures are now being performed by using a minimally invasive approach. Should all the patients are eligible candidates for MIPS? Most of the surgeons, who begin performing MIPS would agree that patient selection is absolutely necessary for the initial patients. The key factors making a patient suitable for the MIS surgery are the straightforward anatomy, non-complex lesions, and patient on the average or lower side for BMI. Patient selection is having a direct impact on the overall success of the MIS. Relative contraindications for the MIPS are patients with previous upper abdominal surgeries such as complex gastric and biliary procedures, and patients with chronic pancreatitis. These conditions make difficult anatomical planes for dissection leading to high risk of damage to vital vascular structures and conversion/complication rates. Large bulky tumors that make manipulations difficult and significant vascular involvement are other factors that make the dissection difficult even for the experienced surgeons. Kendrick et al.42 reported the feasibility of vascular resections by laparoscopic approach for PD further expanding the horizon for MIS. Baumgartner et al.43 recently reported the ability to perform arterial resection during robotic PD. Neoadjuvant radiotherapy and chemotherapy further make the anatomical planes difficult to dissect and may be relative contraindication for MIPS.
10.
Training and learning curves
MIS for PD requires extensive training and is associated with longer learning curves. This is mainly based on the fact that traditionally pancreatic surgery is performed by using an open technique, to which the pancreatic surgeons are familiar with. The present era is different, wherein surgical trainees are taught the basic laparoscopic techniques during their postgraduate training. This leads to the development of the mindset of a minimally invasive surgeon, and it is these surgeons, who have a shorter learning curve for performing any new minimally invasive procedure. The video recording of the minimally invasive procedures further shortens the learning curve for a particular procedure. The technique of laparoscopic resection has led to several modifications of the open surgical steps because of greater understanding of the tissue planes, anatomy, dissection method, and instrumentation.
Please cite this article in press as: Dhamija N, et al. Minimally invasive pancreaticoduodenectomy – A review, Curr Med Res Pract. (2016), http://dx.doi.org/10.1016/j.cmrp.2016.01.002
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11.
Conclusion
Minimally invasive PD is a feasible option in the hands of experienced laparoscopic and robotic surgeon. Proper patient selection is necessary especially during the early phase for successful completion of minimally invasive procedure. Both laparoscopic and robotic PDs have shown good results in recent reports with oncological safety. Mere presence of a robot at the institution should not be the driving force to do minimally invasive PD. The surgeons should go through a well-designed training process as strong as for surgeon, who performs a traditional open PD. For those surgeons, who have extensive experience in performing minimally invasive pancreatic resections, it has become evident that minimally invasive approach has served to improve the open pancreatic resections by applying what we have learned from the minimally invasive approach. MIPS is going to stay. Further studies are needed to compare the advantages of this approach over the traditional open PD prior to stating that it should be considered the approach of choice.
Conflicts of interest The authors have none to declare.
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