| The pancreatic neoplasms traditionally have been treated by standard pancreatectomy (pancreaticoduodenectomy or distal pancreatectomy). The patients with benign or low-grade malignant neoplasm of the pancreas can be expected to survive long term. Therefore, standard pancreatectomy for these neoplasms could result in a significant loss of normal pancreatic tissue and spleen without a real oncological need and with subsequent impairment of exocrine and endocrine pancreatic function and splenic function. With the development of surgical techniques and application of precise surgery, parenchyma-sparing resections of the pancreas have increasingly become an option to treat these tumors.The revolution in laparoscopic surgery developed only after the French gynecologist Mouret performed in1987the first acknowledged laparoscopic cholecystectomy. The first Laparoscopic Enucleation(LE), Laparoscopic Spleen-Preserving Distal Pancreatectomy(LSPDP)was performed by Gagner in1996and Laparoscopic Central Pancreatectomy(LCP) by Baca in2003. All of these procedures had significant advantages of minimally invasion with small incision, lower blood loss and rapid postoperative recovery and function-preserving of pancreas and spleen.Because little surgeon was experienced in pancreatic and advanced laparoscopic surgery. The papers reported in the literature are mostly few-case reports or small series and mainly with respect to surgical techniques. Comparative studies about function-preserving laparoscopic pancreatectomy (LE, LSPDP and LCP) are limited. Moreover, the organ function and quality of life (QOL) after the operation have not been presented in the literature to date.In February2001, we performed LE for pancreatic cyst which was the first case in China. With the accumulation of surgical experience, more complex procedures such as LDP (LSPDP) and LCP were performed in our hospital. To investigate the safety and feasibility of function-preserving laparoscopic pancreatic surgery (LE, LSPDP and LCP) and the organ function after the operation, a retrospective comparative study was performed for function-preserving laparoscopic pancreatic surgery (LE, LSPDP and LCP) which were performed in our hospital. In addition, the organ function after the operation was evaluated by the follow-up study. Moreover, the initial exploration of the strategy and surgical approach for laparoscopic management of the neoplasm in the distal part (neck+body+tail) of the pancreas was performed.Part1:Laparoscopic Versus Open Enucleation for Pancreatic Lesions:Clinical Outcomes and Pancreatic Function AnalysisObjective:1.To investigate the safety and feasibility of LE.2. To evaluate the pancreatic function after LE.Methods:From February2001to November2013, the patients who were scheduled to receive pancreatic enucleation were included in this study. Exclusion criteria were palliative operation and conversion to laparotomy. The patients were divided into two groups based on the surgical approach:the LE group and the open enucleation (OE) group. The safety and feasibility of LE were investigated by comparing the short-term outcomes of the two groups. The pancreatic function after LE was assessed by fasting blood glucose level (endocrine function), clinical evaluation (exocrine function). The Chinese version of SF-36questionnaire was used to assess the QOL after the operation, and the results were compared between these two groups.Results:Totally,39cases were included in this study, including13cases in the LE group and26cases in the OE group. There were no significant differences between the two groups with respect to sex, age, BMI, symptoms, comorbidity, history of abdominal surgery and ASA status (P>0.05)Patients undergoing LE had a shorter operative time (131.9±48.5min vs158.2±41.8min). However, this difference was not statistically significant (P=0.088). The LE group was associated with lower amount of intraoperative blood loss [80(20-450) ml vs200(50-1000) ml, P=0.004], and without transfusion.There were no significant differences in postoperative complication rates (30.8%vs38.5%, P=0.733), major complications rates (>Grade III)(7.7%vs7.7%, P=1.000), pancreatic fistula rates (≥Grade B:15.4%vs11.5%, P=0.777), bleeding rates (0vs3.8%,P=1.000), infection rates (15.4%vs15.4%, P=1.000) between the two groups. Patients in the LE group recovered much faster. Its time to out-of-bed activity (1.5±0.8d vs2.6±0.6d, P=0.001), first flatus (1.7±1.0d vs3.4±1.7d, P=0.004), first liquid diet(2.4±1.0d vs4.3±1.9d, P=0.001) and postoperative hospital stay(7.3±3.0d vs11.4±5.6d, P=0.006) were significantly shorter than those in the OE group. Moreover, the LE group had lower VAS pain scores than those in the OE group (1.7±0.5vs2.5±0.8, P=0.019).The White Blood Cell(WBC) counts(10.7±3.3*109/L vs15.3±3.9*109/L, P=0.007) and C-reactive protein(CRP) value (36.0±27.2mg/L vs82.1±23.0mg/L, P=0.042) on postoperative days (POD)1were significantly lower in the LE group than in the OE group, and there were no significant difference at the other time point (P>0.05). There were no significant difference in alanine aminotransferase、albumin、blood urea nitrogen and creatinine value between the two groups at any time point(POD1,3,5, and7)(P>0.05).There were no significant difference in endocrine (9.1%vs8.7%) or exocrine (9.1%vs4.3%) dysfunction after tumor enucleations between the two groups (P>0.05). Following tumor enucleations, the incidence of new postoperative diabetes was2.9%, and impaired glucose tolerance was5.95%. The incidence of weight loss (>10%preoperative body weight) or (<10%preoperative body weight) was2.9%and5.9%, respectively. Diarrhea developed in5.9%patients.In the assessment of QOL (SF-36) after operation, the total QOL score (702.9±47.9vs671.8±94.1).physical health score(353.9±24.8vs326.6±67.6) and mental health score(349.0±26.5vs345.2±34.6) were higher in the LE group compared with the OE group. However, these differences were not statistically significant (P>0.05). The score in role-physical (100vs73.1±4.8, P=0.042) was significantly higher in LE group, and not statistically significant in other scales (P>0.05)Conclusion:1. LE is a procedure as safe and feasible as OE.2. LE is associated with lower postoperative pain and inflammatory response, faster postoperative recovery, pancreatic function preservation, improved quality of life.Part2:Clinical comparison of Laparoscopic Distal Pancreatectomy with or without Splenectomy:Clinical Outcomes and Splenic Function AnalysisObjective:1.To investigate the safety and feasibility of LSPDP.2. To evaluate the function of spleen salvage.3. To investigate the learning curve for LSPDP.Methods:From March2004to November2013, the patients who were scheduled to receive laproscopic distal pancreatectomy were included in this study. Exclusion criteria were pancreatic adenocarcinoma and conversion to laparotomy. The patients were divided into two groups based on the surgical approach:the LSPDP group and the laparoscopic distal pancreatosplenectomy (LDPS) group. The safety and feasibility of LSPDP were investigated by comparing the short-term outcomes of the two groups. The function of spleen salvage was assessed by comparing White blood cell(WBC), Hemoglobin(Hgb), Platelet(PLT), C-reactive protein (CRP), Chinese version of SF-36questionnaire between the two groups and the patency of splenic vessels after LSPDP. In addition, all patients were divided into the early group, the medium group and the late group. The operative time, blood loss, postoperative hospital stay and postoperative morbidity among the three groups were compared to investigate the learning curve for LSPDP.Results:Totally,104cases were included in this study, including34cases in the LSPDP group and70cases in the LDPS group. There were no significant differences between the two groups with respect to sex, age, BMI, symptoms, comorbidity, history of abdominal surgery and ASA status (P>0.05).There were no significant differences in the selection of the white or blue cartridge between the two groups (P=0.266). Patients undergoing LSPDP had a shorter operative time(173.3±46.4min vs193.9±54.4min), lower amount of intraoperative blood loss(154.1±174.8ml vs223.6±186.6ml).However, these differences were not statistically significant (P>0.05).There were no significant differences in postoperative complication rates(41.2%vs38.6%, P=0.946), major complications rates (≥Grade Ⅲ)(8.8%vsl4.3%, P=0.57), pancreatic fistula rates (≥Grade B:11.8%vs15.7%, P=0.958), bleeding rates (5.9%vs0, P=0.105), infection rates (11.8%vs20%, P=0.298) between the two groups. There were no significant differences with respect to time to out-of-bed activity, first flatus, first liquid diet and postoperative hospital stay (P>0.05). Moreover, the LSPDP group had lower VAS pain scores than those in the LDPS group (1.4±0.7vs1.9±0.8, P=0.003).WBC counts on POD1were significantly lower in the LSPDP group than in the LDPS group (9.4±2.2*109/L vs14.6±4.9*109/L, P=0.000), and this difference continued until POD7. PLT counts on POD3were significantly lower in the LSPDP group than in the LDPS group (144±50.7*109/L vs178.4±58.3*109/L, P=0.019), and this difference continued until POD30. On POD14, LDPS group had more cases of PLT≥300*109/L than the LSPDP group (84.3%vs46.7%, P=0.000).There was no significant difference in Hgb and CRP counts between the two groups at any time point (P>0.05).Among34patients with LSPDP,32patients underwent splenic vessel-preserving. One patient underwent transcatheter microcoil embolization of the splenic artery for the splenic arterial pseudoaneurysm. Four patients (11.8%) developed spleen focal infarction within1month of surgery, and none presented clinical relevant symptoms. The perfusion of the spleen recovered6months after operation. Three patients (8.8%) with splenic vein stenosis or occlusion developed collateral venous vessels around gastric fundus and reserved spleen; one patient developed variceal bleeding within1month of surgery. The other patients were with normal patency of the splenic vessels.In the assessment of QOL (SF-36) after operation, the total QOL score (635.8±50.7vs596.1±92.1), physical health score(320.2±32.3vs305.6±46.1) and mental health score(315.5±35.2vs290.0±51.1) were higher in the LSPDP group compared with the LDPS group. However, these differences were not statistically significant (P>0.05). The score in vitality(82.5±14.4vs68.9±11.4, P=0.046) was significantly higher in the LSPDP group, and not statistically significant in other scales (P>0.05).About the learning curve of LSPDP, the operative time of the late group (146.4±31.6min) were significantly lower than that in the early group (187.7±37.2min, P=0.033)and the medium group(185.9±57.4min, P=0.041). Moreover, the blood loss (57.2±29.4ml vs236.4±250.1ml, P=0.01) and postoperative hospital stay (7.4±2.3d vs10.7±4.5d, P=0.025) of the late group were significantly lower than that in the early group. The postoperative morbidity progressively declined from the early group to the late group (54.5%vs41.7%vs27.3%)。But there were no significant difference among the three groups (P=0.429).Conclusion:1. LSPDP is a procedure as safe and feasible as LDPS.2. LSPDP is associated with lower postoperative pain, splenic function preservation, improved quality of life.3. On the basis of skilled surgical techniques for laparoscopic pancreatectomy, the learning curve for LSPDP was roughly20cases. Surgeons could better perform the advantages of the LSPDP after reaching the learning curve. Part3:Laparoscopic Versus Open Central Pancreatectomy:Clinical Outcomes and Pancreatic Function AnalysisObjective:1.To investigate the safety and feasibility of LCP.2. To evaluate the pancreatic function after LCP.Methods:From December1997to November2013, the patients who were scheduled to receive central pancreatectomy (CP) were included in this study. Exclusion criteria were pancreatic adenocarcinoma and conversion to laparotomy. The patients were divided into two groups based on the surgical approach:the LCP group and the open central pancreatectomy (OCP) group. In addition, the patients in OCP group were divided into pancreaticojejunostomy (PJ) and pancreatogastrostomy (PG) subgroup. The safety and feasibility of LCP were investigated by comparing the short-term outcomes of LCP group and OCP group, LCP group and OCP (PJ) subgroup. The pancreatic function after LCP was assessed by fasting blood glucose level, insulin, C-peptide (endocrine function), Fecal elastase-1, and clinical evaluation (exocrine function).Results:Totally,41cases were included in this study, including12cases in the LCP group and29cases in the OCP group. There were no significant differences between the two groups with respect to sex, age, BMI, symptoms, comorbidity, history of abdominal surgery and ASA status (P>0.05).The pancreaticojejunal reconstruction under laparoscopy was executed with a duct-to-mucosa PJ (n=2) or end-to-side PJ (n=10). However, PJ (duct-to-mucosa/end-to-side/binding PJ, n=1/7/7) or PG (n=14) was executed under laparotomy (P=0.009).Patients undergoing LCP had a longer operative time (282.9±28.6min vs280.4±74.8min). However, this difference was not statistically significant (P=0.876). The LCP group was associated with lower amount of intraoperative blood loss [50(30-300) mlvs250(50-1200) ml, P=0.000], and without transfusion.There were no significant differences in postoperative complication rates(58.3%vs65.5%, P=0.938), major complications rates (>Grade Ⅲ)(33.3%vs20.7%, P=0.647),pancreatic fistula rates (≥Grade B:25%vs37.9%, P=0.665),bleeding rates (33.3%vs13.8%, P=0.195),infection rates (25%vs34.5%, P=0.822), reoperation rates (33.3%vs6.9%, P=0.09) between the two groups. Patients in the LCP group recovered much faster. Its time to out-of-bed activity (2.3±0.5d vs5.1±2.8d, P=0.009), first flatus(2.3±0.9d vs4.3±1.3d, P=0.000)and first liquid diet[4(2-11)d vs7(3-13)d, P=0.001] were significantly shorter than those in the OCP group. Moreover, the LCP group had lower VAS pain scores than those in the OCP group [2(1-3) vs3(2-5), P=0.005].Patients undergoing LCP had a shorter postoperative hospital stay [11.5(6-43) d vs14(8-119) d]. However, this difference was not statistically significant (P=0.222).The CRP value on POD1were significantly lower in the LCP group than in the OCP group (43.0±24.8mg/L vs73.5±34.3mg/L, P=0.035), and there were no significant difference at the other time point (P>0.05). The ALT value (11.5±3.2IU/L vs21.7±16.1IU/L, P=0.032),(8.2±1.6IU/L vs24.1±13.6IU/L, P=0.002) on POD3,5were significantly lower in the LCP group, and there were no significant difference at the other time point (P>0.05). There were no significant differences in WBC, ALB, BUN and CR value between the two groups at any time point (POD1,3,5, and7).There were no significant difference in endocrine (9.1%vs16%) or exocrine (0vs8.0%) dysfunction after CP between the two groups (P>0.05). Following the CP, the incidence of new postoperative diabetes was5.6%, and impaired glucose tolerance was 8.3%. The incidence of weight loss (≥10%preoperative body weight) or (<10%preoperative body weight) was5.6%and2.8%, respectively. Diarrhea developed in2.8%patients. Comparison of the pre-and postoperative endocrine or exocrine function of the LCP group did not reveal any significant difference in terms of fasting blood glucose level (P=0.099),insulin (P=0.898),C-peptide (P=0.645), Fecal elastase-1(P=0.901).As comparing with OCP (PJ) subgroup, patients undergoing LCP had a shorter operative time (282.9±28.6min vs298.5±62.5min). However, this difference was not statistically significant (P=0.399). The LCP group was associated with lower amount of intraoperative blood loss[50(30-300) mlvs250(50-1200) ml, P=0.000], and without transfusion. There were no significant differences in postoperative complication rates, major complications rates (≥Grade Ⅲ),pancreatic fistula rates, bleeding rates, infection rates, reoperation rates between the LCP group and OCP(PJ)subgroup. Patients in the LCP group recovered much faster. Its time to out-of-bed activity, first flatus and first liquid diet were significantly shorter than in the OCP (PJ) subgroup (P<0.05) However, the postoperative hospital stay was not significantly different between the LCP group and OCP (PJ) subgroup (P>0.05). In the LCP group and OCP (PJ) subgroup, both one patient developed the impaired glucose tolerance with diet control. One patient in the OCP (PJ) subgroup developed weight loss (<10%preoperative body weight).Conclusion:1. LCP is a procedure as safe and feasible as OCP.2. LCP is associated with lower postoperative pain and inflammatory response, faster postoperative recovery, pancreatic function preservation.Part4:The Strategy and Surgical Approach for Laparoscopic Management of the Neoplasm in the Distal Part (neck+body+tail) of the PancreasDue to the complexity of the pancreatic anatomy and physiological function, the development of laparoscopic pancreatic surgery has been relatively slowly. Our goal is to promote the concept and technique of the laparoscopic pancreatectomy. The initial exploration of the strategy and surgical approach for laparoscopic management of the neoplasms in the distal part (neck+body+tail) of the pancreas was performed on basis of our experience in laparoscopic pancreatic surgery. |
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