RESUMEN
In its 20th anniversary, laparoscopic pancreatoduodenectomy, while feasible and safe in the hands of experienced surgeons, has not seen the anticipated popularity observed in other digestive surgery procedures. The primary hurdle remains the absence of a clear advantage over traditional open surgery, paired with the procedures complexity and a consequent steep learning curve. In regions with limited pancreatic surgery services, conducting this procedure without adequate training can have serious repercussions. Given the advent of robotic platforms and the anticipation of prospective and randomized studies on this new technology, it is imperative to engage in comprehensive discussions, endorsed by surgical societies, on the value, application, and implementation strategies for various minimally invasive pancreatoduodenectomy techniques. Such dialogue is crucial for advancing the field and ensuring optimal patient outcomes.
Asunto(s)
Laparoscopía , Pancreaticoduodenectomía , Pancreaticoduodenectomía/métodos , Pancreaticoduodenectomía/tendencias , Laparoscopía/tendencias , Laparoscopía/métodos , Laparoscopía/educación , Humanos , Factores de TiempoRESUMEN
BACKGROUND: The feasibility and safety of laparoscopic pancreatoduodenectomy (LPD) in elderly patients is still controversial. This study aimed to compare the clinical outcomes of LPD and open pancreatoduodenectomy (OPD) in elderly patients. METHODS: Clinical and follow-up data of elderly patients (≥ 65 years) who underwent LPD or OPD between 2015 and 2022 were retrospectively analyzed. A 1:1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality. RESULTS: Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 vs. 200 mL, P < 0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P = 0.029), more lymph node harvest (11.0 vs. 10.0, P = 0.014) and shorter postoperative length of stay (LOS) (13.0 vs. 16.0 days, P = 0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P > 0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 vs.20.4 months, P = 0.672) after PSM. CONCLUSIONS: It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS. There was no statistically significant difference in long-term survival outcomes between elderly PDAC patients who underwent LPD or OPD.
Asunto(s)
Laparoscopía , Neoplasias Pancreáticas , Pancreaticoduodenectomía , Puntaje de Propensión , Humanos , Pancreaticoduodenectomía/métodos , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/tendencias , Anciano , Masculino , Femenino , Laparoscopía/métodos , Laparoscopía/efectos adversos , Laparoscopía/tendencias , Estudios Retrospectivos , Neoplasias Pancreáticas/cirugía , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Anciano de 80 o más Años , Factores de Tiempo , Tiempo de Internación/tendenciasAsunto(s)
Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/tendencias , Edad de Inicio , Anciano , Femenino , Predicción , Fragilidad , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/efectos adversos , Complicaciones Posoperatorias , Resultado del TratamientoRESUMEN
BACKGROUND/AIM: The potential benefits of pancreatectomy with major arterial resection have been studied in the past, but findings remain controversial. Pancreatic neck/body cancer (PNBC) involving arteries frequently requires combined resection of the pancreas, artery and portal vein. PATIENTS AND METHODS: Nine prospectively-registered consecutive patients with PNBC were enrolled, all underwent pancreatoduodenectomy with common hepatic artery en-bloc resection (PD-CHAR). We investigated the safety of PD-CHAR by blood flow evaluation with intraoperative indocyanine green fluorescence imaging in reconstructed vessels/organs. RESULTS: Among patients who underwent PD-CHAR, there was no severe morbidity. Artery/portal vein combined resection and reconstruction was performed in all patients. Four (44%) patients had pathological positivity for cancer cell invasion into the nerve plexus of artery at the site of radiographic artery involvement, although one (11%) was diagnosed with pathological artery involvement. CONCLUSION: PD-CHAR following neoadjuvant therapy might be feasible for PNBC without severe postoperative complications. Survival benefits in PNBC should be confirmed in further studies.
Asunto(s)
Adenocarcinoma/cirugía , Arteria Hepática/cirugía , Páncreas/cirugía , Neoplasias Pancreáticas/cirugía , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/patología , Adulto , Anciano , Femenino , Arteria Hepática/patología , Humanos , Verde de Indocianina/administración & dosificación , Masculino , Persona de Mediana Edad , Páncreas/patología , Neoplasias Pancreáticas/diagnóstico por imagen , Neoplasias Pancreáticas/patología , Pancreaticoduodenectomía/tendencias , Proyectos Piloto , Vena Porta/patología , Vena Porta/cirugía , Complicaciones Posoperatorias , Neoplasias PancreáticasRESUMEN
The surgical treatment of pancreatic cancer (PDAC) has seen sweeping changes during the past 5 decades. Up to the middle of the 20th century resection rates were below 5%, but the numbers of curative resections for PDAC are now continuously increasing due to improved neoadjuvant treatment concepts as well as progress in surgical techniques and perioperative management. During the same period, mortality rates after pancreatic surgery have decreased considerably and are now less than 5%. One of the most important cornerstones of reduced mortality has been the concentration of PDAC surgery in specialized centers. In addition, the management of postoperative complications has improved greatly as a result of optimized interdisciplinary teamwork. Adjuvant chemotherapy has become the reference treatment in resected PDAC, achieving significantly prolonged survival. Moreover, the concept of borderline resectable PDAC has emerged to characterize tumors with increased risk for tumor-positive resection margins or worse outcome. The best treatment strategy for borderline resectable PDAC is currently under debate, whereas neoadjuvant therapy has become established as a beneficial treatment option for patients with locally advanced PDAC, enabling conversion surgery in up to 60% of cases. This review article summarizes the principal changes in PDAC surgery during the past 50 years.
Asunto(s)
Carcinoma Ductal Pancreático/cirugía , Laparoscopía/métodos , Pancreatectomía/métodos , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma Ductal Pancreático/tratamiento farmacológico , Quimioterapia Adyuvante/métodos , Quimioterapia Adyuvante/tendencias , Humanos , Laparoscopía/tendencias , Terapia Neoadyuvante/métodos , Terapia Neoadyuvante/tendencias , Pancreatectomía/tendencias , Neoplasias Pancreáticas/tratamiento farmacológico , Pancreaticoduodenectomía/tendencias , Factores de TiempoRESUMEN
Remarkable progress has been made in treating pancreatic cancer over the past century, including refinement of our surgical techniques and improvements in adjuvant and neoadjuvant therapies. Despite these advances, the incidence of pancreatic cancer is rising globally, and it remains a deadly disease. In this review, we highlight the historical perspectives of pancreatic cancer treatment and outline the areas of future advancement that will assist progression towards better outcomes. Areas of future advancement include improving prevention strategies and early detection, refining our molecular understanding of pancreatic cancer, identifying more effective systemic therapies, and improving quality of life and surgical outcomes. Furthermore, systems need to be put in place to ensure all patients with pancreatic cancer receive high quality care and are given the appropriate options and sequence of therapy. This is best achieved through multidisciplinary care.
Asunto(s)
Neoplasias Pancreáticas/terapia , Quimioterapia Adyuvante/métodos , Quimioterapia Adyuvante/tendencias , Terapia Combinada/tendencias , Detección Precoz del Cáncer/tendencias , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Terapia Neoadyuvante/métodos , Terapia Neoadyuvante/tendencias , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/tendencias , Calidad de Vida , Tasa de SupervivenciaRESUMEN
This review focused on the progress in laparoscopic pancreaticoduodenectomy(LPD) in the past six years.With the appropriate approaches under laparoscopy, including the resection and reconstruction, LPD has been proved to be safe and feasible. In some centers, LPD has been routine with rapid growth of numbers, it not only benefit the patients with fast recovery, but also benefit the trainees with similar sights as the primary surgeon and good videos of the procedures. However, LPD is still controversial as the more complications in some centers and inconclusive oncologic outcomes. Thus, in the further, a long-time outcome monitoring of LPD is essential. A registry of a prospectively maintained database may be a need for LPD to evaluate its outcomes by multicenter randomized control trials, and real world research may be of value. Structured LPD training programs are valuable for the new surgeons.
Asunto(s)
Neoplasias del Sistema Digestivo/cirugía , Pancreaticoduodenectomía/métodos , Humanos , Laparoscopía , Pancreaticoduodenectomía/educación , Pancreaticoduodenectomía/tendencias , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de RegistrosRESUMEN
BACKGROUND: Pancreaticoduodenectomy is a challenging surgical intervention that remains the cornerstone in the treatment of localized periampullary pathologies. The concept of treatment standardization has been well-established in many high-volume centers in the world. Here, we present our experience in pancreaticoduodenectomy from 1994 to 2015. METHODS: We performed a retrospective review of the medical charts of patients who underwent pancreaticoduodenectomy at our institution. Data was entered to SPSS statistical software and analyzed. The Mann-Whitney U and Fisher's exact tests were used to report statistical differences between groups. RESULTS: Of the 370 patients who underwent pacreaticoduodenectomy, 300 were analyzed. The 1-, 3-, 5- and 10-year survival rates were 85%, 35%, 15%, and 7%, respectively with a 30-day mortality rate of 5.0% (15 patients). The median age of the patients was 61 (13-84) years, with 193 (64.3%) males and 107 (35.7%) females. The median operative time was 300 (130-570) min. The median postoperative length of hospital stay was 12 (5-76) days. Thirty-two patients required re-laparotomies; 10 for pancreatic leak, 7 for biliary leak and 15 for control of bleeding. Seventy-five (25.0%) patients developed pancreatic fistulae. Delayed gastric emptying was present in 31 (10.3%) patients. A significant improvement in surgical outcome was observed in cases done after 2008 which indicates the important role of specialized team in surgical management. CONCLUSIONS: The number of patients undergoing pancreaticoduodenectomy has been increasing annually over the past twenty-two years in our institution with results comparable to published series from high-volume centers. Through standardization of surgical techniques and perioperative management carried out by a specialist team, our results continue to improve despite the increasing complexity of cases referred to our unit.
Asunto(s)
Conductos Biliares/cirugía , Neoplasias del Sistema Digestivo/cirugía , Conductos Pancreáticos/cirugía , Fístula Pancreática/etiología , Pancreaticoduodenectomía/estadística & datos numéricos , Hemorragia Posoperatoria/etiología , Especialización/tendencias , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Competencia Clínica , Neoplasias del Sistema Digestivo/patología , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Medio Oriente , Estadificación de Neoplasias , Tempo Operativo , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/normas , Pancreaticoduodenectomía/tendencias , Hemorragia Posoperatoria/cirugía , Estándares de Referencia , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Tasa de Supervivencia , Adulto JovenRESUMEN
"Artery-first approach" encompasses different aspects for the surgical treatment of pancreatic cancer. It is a surgical technique or set of techniques which share in common the dissection of the main arterial vasculature involved in pancreatic cancer, before any irreversible surgical step is performed. On the other hand it represents the need for a meticulous dissection of the arterial planes and clearing of the retropancreatic tissue between the superior mesenteric artery, the common hepatic artery and portal vein in an attempt to achieve R0 resections. The recent expansion of this approach is based mainly on three factors: venous involvement should not be considered a contraindication for resection, most of the pancreatic resections performed with a standard procedure may be in fact non-oncological (R1) resections and the postero-medial or vascular margin is the most frequently invaded by the tumor. This review aimed to summarize and update the artery-first approach in pancreaticoduodenectomy.
Asunto(s)
Páncreas/cirugía , Neoplasias Pancreáticas/irrigación sanguínea , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Contraindicaciones de los Procedimientos , Arteria Hepática , Humanos , Márgenes de Escisión , Arteria Mesentérica Superior/cirugía , Invasividad Neoplásica , Páncreas/anatomía & histología , Páncreas/irrigación sanguínea , Enfermedades Pancreáticas/cirugía , Neoplasias Pancreáticas/patología , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/tendencias , Vena Porta , Pronóstico , Resultado del TratamientoRESUMEN
Pancreatic ductal adenocarcinoma is the fourth deadliest malignancy in developed countries and is predicted to become the second one within the 2030. The present work focuses on the state of the art of laparoscopic pancreaticoduodenectomy, including results of recent randomized trials, and discusses technical challenge and patients' interest of this technique.
Asunto(s)
Carcinoma Ductal Pancreático/cirugía , Laparoscopía/métodos , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Predicción , Objetivos , Humanos , Laparoscopía/tendencias , Metaanálisis como Asunto , Pancreaticoduodenectomía/tendencias , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios RetrospectivosRESUMEN
BACKGROUND: Over the years, high-volume pancreatic centers expanded their indications for pancreatoduodenectomy (PD) but with unknown impact on surgical and oncological outcome. METHODS: All consecutive PDs performed between 1992-2017 in a single pancreatic center were identified from a prospectively maintained database and analyzed according to three time periods. RESULTS: In total, 1434 patients underwent PD. Over time, more elderly patients underwent PD (P < 0.001) with increased use of vascular resection (10.4 to 16.0%, P < 0.001). In patients with cancer (n = 1049, 74.8%), the proportion pT3/T4 tumors increased from 54.3% to 70.6% over time (P < 0.001). The postoperative pancreatic fistula (16.0%), postpancreatectomy hemorrhage (8.0%) and delayed gastric emptying (31.0%) rate did not reduce over time, whereas median length of stay decreased from 16 to 12 days (P < 0.001). The overall failure-to-rescue rate (6.9%) and in-hospital mortality (2.2%) remained stable (P = 0.89 and P = 0.45). In 523 patients with pancreatic cancer (36.5%), the use of both adjuvant and neoadjuvant chemotherapy increased over time (both p<0.001), and the five-year overall survival improved from 11.0% to 17.4% (P < 0.001). CONCLUSIONS: In a period where indications for PD expanded, with more elderly patients, more advanced cancers and increased use of vascular resections, surgical outcome remained favorable and five-year survival for pancreatic cancer improved.
Asunto(s)
Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/tendencias , Pautas de la Práctica en Medicina/tendencias , Procedimientos Quirúrgicos Vasculares/tendencias , Factores de Edad , Anciano , Quimioterapia Adyuvante , Toma de Decisiones Clínicas , Bases de Datos Factuales , Fracaso de Rescate en Atención a la Salud/tendencias , Femenino , Mortalidad Hospitalaria/tendencias , Hospitales de Alto Volumen , Humanos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante/tendencias , Estadificación de Neoplasias , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/patología , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/mortalidad , Selección de Paciente , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years. METHODS: Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics. RESULTS: A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015. CONCLUSIONS: This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.
Asunto(s)
Neoplasias Pancreáticas/epidemiología , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/tendencias , Pautas de la Práctica en Medicina/tendencias , Cirujanos/tendencias , Distribución por Edad , Anciano , Brasil/epidemiología , Femenino , Necesidades y Demandas de Servicios de Salud/tendencias , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Evaluación de Necesidades/tendencias , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/mortalidad , Sistema de Registros , Estudios Retrospectivos , Distribución por Sexo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Despite improvements in therapy regimens over the past decades, overall survival rates for pancreatic and periampullary cancer are poor. Specific cancer registries are set up in various nations to regional differences and to enable larger prospective trials. The aim of this study was to describe the Swedish register, including possibilities to improve diagnostic work-ups, treatment, and follow-up by means of the register. METHODS: Since 2010, all patients with pancreatic and periampullary cancer (including also patients who have undergone pancreatic surgery due to premalignant or benign lesions) have been registered in the Swedish National Periampullary and Pancreatic Cancer registry. RESULTS: In total 9887 patients are listed in the registry; 8207 of those have malignant periampullary cancer. Approximately one-third (3282 patients) have had resections performed, including benign/premalignant resections. 30-day and 90-day mortality after pancreatoduodenectomy is 1.5% and 3.5%, respectively. The overall 3-year survival for resected pancreatic ductal adenocarcinoma is 35%. Regional variations decreased over the studied period, but still exist. CONCLUSION: Results from the Swedish National Registry are satisfactory and comparable to international standards. Trends over time show increasing resection rates and some improved results. Better collaboration and openness within pancreatic surgeons is an important side effect.
Asunto(s)
Ampolla Hepatopancreática/cirugía , Neoplasias del Conducto Colédoco/cirugía , Neoplasias Duodenales/cirugía , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía , Pautas de la Práctica en Medicina , Ampolla Hepatopancreática/patología , Neoplasias del Conducto Colédoco/mortalidad , Neoplasias del Conducto Colédoco/patología , Neoplasias Duodenales/mortalidad , Neoplasias Duodenales/patología , Humanos , Neoplasias Pancreáticas/mortalidad , Neoplasias Pancreáticas/patología , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/mortalidad , Pancreaticoduodenectomía/tendencias , Pautas de la Práctica en Medicina/tendencias , Mejoramiento de la Calidad/tendencias , Indicadores de Calidad de la Atención de Salud/tendencias , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Suecia/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Post-pancreaticoduodenectomy hemorrhage has an estimated incidence of 5% and a mortality rate of 11-38%. Vascular erosion resulting from pancreatic leak and skeletonization of the arterial wall during pancreatic mobilization may be the two possible mechanisms responsible for this complication, which most commonly affects the gastroduodenal artery stump. A novel technique of wrapping up the gastroduodenal artery stump into the jejunal serosa to decrease postoperative hemorrhage is presented.
Asunto(s)
Procedimientos Quirúrgicos del Sistema Digestivo/métodos , Duodeno/cirugía , Yeyuno/cirugía , Pancreatectomía/efectos adversos , Pancreaticoduodenectomía/efectos adversos , Hemorragia Posoperatoria/prevención & control , Anciano , Duodeno/irrigación sanguínea , Femenino , Humanos , Yeyuno/irrigación sanguínea , Masculino , Persona de Mediana Edad , Pancreatectomía/tendencias , Pancreaticoduodenectomía/tendencias , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/etiología , Membrana Serosa/irrigación sanguínea , Membrana Serosa/cirugía , Estómago/irrigación sanguínea , Estómago/cirugíaRESUMEN
BACKGROUND: In 2007, Gockel et al. coined the term mesopancreas (MP). In the next 10 years, a limited number of publications about MP have been published, but little is known about the oncological benefit of MP resection. We performed a systematic review of the literature on MP. METHODS: An electronic search was performed in PubMed, EMBASE, Cochrane, Latindex, Scielo, and Koreamed databases until 15 June 2017 to identify all published articles dealing with the subject of MP. Some language restriction was done (Chinese and Rumanian). RESULTS: The search yielded 51 articles; 28 articles were selected as relevant. All were retrospective studies focused more on describing technical variants, feasibility and safety than on the cancer results. The R0 rate in patients with MP resection ranged between 57 and 96.7%. In all the articles with a control group, the R0 rate was higher in the MP excision group. Survival data were explicitly stated only in five series. CONCLUSION: MP is a difficult-to-excise retropancreatic area. In theory, it is agreed that MP excision raises the rate of R0 resections, which in turn reflected in an improvement in the oncological results; however, at present there are no randomized studies to prove this. Achieving a worldwide consensus on its concept, landmarks, excision technique and oncological results is essential.
Asunto(s)
Páncreas , Humanos , Páncreas/patología , Páncreas/fisiología , Páncreas/cirugía , Neoplasias Pancreáticas/prevención & control , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/métodos , Pancreaticoduodenectomía/tendencias , Estudios Retrospectivos , Terminología como AsuntoRESUMEN
BACKGROUND: In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, and independent predictors for FTR investigated. METHODS: Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis. RESULTS: Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2-3.9), age >75 years (OR = 4.3, 1.8-10.2), BMI ≥30 (OR = 2.9, 1.3-6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1-3.7), and hospital volume <30 (OR = 3.9, 1.6-9.6). CONCLUSIONS: Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.
Asunto(s)
Neoplasias del Sistema Digestivo/cirugía , Fracaso de Rescate en Atención a la Salud/tendencias , Disparidades en Atención de Salud/tendencias , Mortalidad Hospitalaria/tendencias , Evaluación de Procesos y Resultados en Atención de Salud/tendencias , Pancreaticoduodenectomía/mortalidad , Complicaciones Posoperatorias/mortalidad , Indicadores de Calidad de la Atención de Salud/tendencias , Anciano , Neoplasias del Sistema Digestivo/mortalidad , Neoplasias del Sistema Digestivo/patología , Femenino , Humanos , Masculino , Auditoría Médica/tendencias , Persona de Mediana Edad , Estadificación de Neoplasias , Países Bajos/epidemiología , Pancreaticoduodenectomía/efectos adversos , Pancreaticoduodenectomía/tendencias , Medición de Riesgo , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Innovation in surgical devices and improvement in laparoscopic skills have gradually led to achieve more challenging surgical procedures. Among these demanding interventions is the pancreatic surgery that is seen as intraoperatively risky and with high postoperative morbi-mortality rate. In order to understand the complexity of laparoscopic pancreatic surgery, we performed a systematic review of literature. DATA SOURCE: A systematic review of literature was performed regarding laparoscopic pancreatic resection. RESULTS: Laparoscopic approach in pancreas resections has been extensively reported as safe and feasible regarding pancreaticoduodenectomy, distal pancreatectomy and pancreatic enucleation. Compared to open approach, no benefit in morbi-mortality has been demonstrated (except for laparoscopic distal pancreatectomy) and no controlled randomized trials have been reported. CONCLUSIONS: Laparoscopic approach is not workable in all patients and patient selection is not standardized. Additionally, most optimistic reports considering laparoscopic approach are produced by tertiary centres. Currently, two tasks should be accomplished 1°) standardization of the laparoscopic pancreatic procedures 2°) comparative trials to assess endpoint benefits of laparoscopic pancreatic resection compared with open procedures.
Asunto(s)
Laparoscopía/métodos , Pancreatectomía/métodos , Pancreaticoduodenectomía/métodos , Humanos , Pancreatectomía/tendencias , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/tendenciasRESUMEN
BACKGROUND: Pancreatic resection for cancer represents a real challenge for every surgeon. Recent improvements in laparoscopic experience, minimally invasive surgical techniques and instruments make now the minimally invasive approach a real "triumph." There is no doubt that minimally invasive surgery has replaced with great success conventional surgery in many fields, including surgical oncology. METHODS AND RESULTS: However, its progress in pancreatic resection for adenocarcinoma has been dramatically slow. Recent evidence supports the notion that minimally invasive distal pancreatectomy is safe and feasible and that is becoming the procedure of choice mainly for benign or low-grade malignant lesions in the distal pancreas. On the other side, minimally invasive pancreatoduodenectomy has not yet been widely accepted and there is enormous skepticism when applied for pancreatic head adenocarcinoma. In this review, we summarize the current evidence on the potential applications of minimally invasive surgical approaches for this aggressive, heterogeneous, and enigmatic type of cancer. CONCLUSIONS: Moreover, the potential future applications of these approaches are discussed with the hope to improve the quality of life as well as the survival rates of pancreatic cancer patients.
Asunto(s)
Adenocarcinoma/cirugía , Laparoscopía/tendencias , Pancreatectomía/tendencias , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/tendencias , Adenocarcinoma/mortalidad , Humanos , Laparoscopía/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/tendencias , Clasificación del Tumor , Tratamientos Conservadores del Órgano/efectos adversos , Tratamientos Conservadores del Órgano/tendencias , Páncreas/patología , Páncreas/cirugía , Pancreatectomía/métodos , Neoplasias Pancreáticas/mortalidad , Pancreaticoduodenectomía/métodos , Calidad de Vida , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/tendencias , Bazo/cirugía , Tasa de Supervivencia , Resultado del Tratamiento , Neoplasias PancreáticasRESUMEN
BACKGROUND: The introduction of minimally invasive pancreatic resection (MIPR) into surgical practice has been slow. The worldwide utilization of MIPR and attitude towards future perspectives of MIPR remains unknown. METHODS: An anonymous survey on MIPR was sent to the members of six international associations of Hepato-Pancreato-Biliary (HPB) surgery. RESULTS: The survey was completed by 435 surgeons from 50 countries, with each surgeon performing a median of 22 (IQR 12-40) pancreatic resections annually. Minimally invasive distal pancreatectomy (MIDP) was performed by 345 (79%) surgeons and minimally invasive pancreatoduodenectomy (MIPD) by 124 (29%). The median total personal experience was 20 (IQR 10-50) MIDPs and 12 (IQR 4-40) MIPDs. Current superiority for MIDP was claimed by 304 (70%) and for MIPD by 44 (10%) surgeons. The most frequently mentioned reason for not performing MIDP (54/90 (60%)) and MIPD (193/311 (62%)) was lack of specific training. Most surgeons (394/435 (90%)) would consider participating in an international registry on MIPR. DISCUSSION: This worldwide survey showed that most participating HPB surgeons value MIPR as a useful development, especially for MIDP, but the role and implementation of MIPD requires further assessment. Most HPB surgeons would welcome specific training in MIPR and the establishment of an international registry.
Asunto(s)
Laparoscopía/tendencias , Pancreatectomía/tendencias , Pancreaticoduodenectomía/tendencias , Pautas de la Práctica en Medicina/tendencias , Procedimientos Quirúrgicos Robotizados/tendencias , Cirujanos/tendencias , Adulto , Actitud del Personal de Salud , Competencia Clínica , Educación Médica Continua , Educación de Postgrado en Medicina , Encuestas de Atención de la Salud , Conocimientos, Actitudes y Práctica en Salud , Humanos , Laparoscopía/educación , Persona de Mediana Edad , Pancreatectomía/educación , Pancreaticoduodenectomía/educación , Procedimientos Quirúrgicos Robotizados/educación , Cirujanos/psicologíaRESUMEN
In recent years, laparoscopic pancreatoduodenectomy (LPD) has been gaining a favorable position in the field of pancreatic surgery. However, its role still remains unclear. This review investigates the current status of LPD in high-volume centers. A literature search was conducted in PubMed, and only papers written in English containing more than 30 cases of LPD were selected. Papers with "hybrid" or robotic technique were not included in the analysis. Out of a total of 728 LPD publications, 7 publications matched the review criteria. The total number of patients analyzed was 516, and the largest series included 130 patients. Four of these studies come from the United States, 1 from France, 1 from South Korea, and 1 from India. In 6 reports, LPDs were performed only for malignant disease. The overall pancreatic fistula rate grades B-C were 12.7%. The overall conversion rate was 6.9%. LPD seems to be a valid alternative to the standard open approach with similar technical and oncological results. However, the lack of many large series, multi-institutional data, and randomized trials does not allow the clarification of the exact role of LPD.