The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis.

BACKGROUND: Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC). METHODS: A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS). RESULTS: Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group. CONCLUSIONS: This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately. PROTOCOL REGISTRATION: PROSPERO (CRD42021277495) on the 25th of October 2021.

Risk factors of posthepatectomy liver failure for perihilar cholangiocarcinoma: Risk score and significance of future liver remnant volume-to-body weight ratio.

BACKGROUND: Surgery for perihilar cholangiocarcinoma (PHCC) is associated with high morbidity. This study aimed to investigate the clinical value of the future liver remnant volume-to-body weight (FLRV/BW) and propose a risk score for predicting the risk of patients with PHCC developing posthepatectomy liver failure (PHLF). METHODS: This study included 348 patients who underwent major hepatectomy with bile duct resection for PHCC during 2008-2015 at a single center in Korea and they were retrospectively analyzed. RESULTS: Clinically relevant PHLF was noted in 40 patients (11.4%). The area under the curve (AUC) for FLRV/BW was not significantly different from that for FLRV/total liver volume (P = .803) or indocyanine green clearance of the future liver remnant (P = .629) in terms of predicting PHLF. On multivariate analysis, predictors of PHLF (P < .05) were male sex, albumin less than 3.5 g/dL, preoperative cholangitis, portal vein resection, FLRV/BW less than 0.5%, and FLRV/BW 0.5% to 0.75%. These variables were included in the risk score that showed good discrimination (AUC, 0.853; 95% CI, 0.802-0.904). It will help rank patients into three risk subgroups with a predicted liver failure incidence of 4.75%, 18.73%, and 51.58%, respectively. CONCLUSIONS: FLRV/BW is a comparable risk prediction factor of PHLF and the proposed risk score can help to predict the risk of planned surgery in PHCC.

Short-term clinical outcomes for 100 consecutive cases of laparoscopic pylorus-preserving pancreatoduodenectomy: improvement with surgical experience.

BACKGROUND: Few reports describe the use of laparoscopic pylorus-preserving pancreaticoduodenectomy (LPPPD) in centers with experience using this technique. In addition, the clinical outcomes of this procedure remain undetermined. METHODS: In the current study, 100 patients with benign or malignant lesions in the pancreatic head underwent LPPPD between May 2007 and December 2011. The overall clinical outcomes and changes in these outcomes during the surgeon learning period were analyzed to assess the feasibility and safety of this procedure. RESULTS: Pathologic examination of the pancreas confirmed intraductal papillary mucinous neoplasms in 37 patients, solid pseudopapillary tumors in 17 patients, neuroendocrine tumors in 15 patients, serous cystic neoplasms in seven patients, pancreatic ductal adenocarcinomas in seven patients, ampulla of Vater tumors and duodenal gastrointestinal stromal tumors in five patients, and other disease in seven patients. The median operative time was 7.9 h, which decreased with accumulating experience of the surgeon using this procedure, from 9.8 h for the first 33 cases to 6.6 h for the last 34 cases. Complications developed in 25% of the patients, including six cases (6%) with significant pancreatic fistula [International Study Group on Pancreatic Fistula (ISGPF) grade B]. The complication rate decreased from 33.3% for the first 33 cases to 17.6% for the last 34 cases. The mean hospital stay was 14 days, which also decreased from 20.4 days for the first 33 cases to 11.5 days for the last 34 cases. For the 12 patients in the study cohort with invasive malignant disease, the median tumor size was 2.8 cm, and the median number of lymph nodes harvested was 13. All the patients had margin-negative R0 resections. CONCLUSION: The LPPPD procedure is technically safe and feasible, with an acceptable rate of morbidity and other clinical outcomes for benign and malignant diseases. Clinical outcomes can be improved once a learning curve has been overcome.

Validating a simple scoring system to predict malignancy and invasiveness of intraductal papillary mucinous neoplasms of the pancreas.

BACKGROUND: The objective of the present study was to identify reliable preoperative factors predicting malignancy or invasiveness of intraductal papillary mucinous neoplasm (IPMN) of the pancreas and the effectiveness of a diagnostic scoring system based on these factors. METHODS: Between August 1994 and December 2007, 204 patients underwent pancreatic resection for IPMN at a single institute. Medical records were reviewed retrospectively, and a new diagnostic scoring system for predicting malignant IPMN preoperatively was designed. RESULTS: Univariate analysis revealed nine significant predictors of both malignant and invasive IPMN: age > or =60 years, history of pancreatitis, presence of mural nodule(s), diameter of main pancreatic duct (MPD) >6 mm, main duct or mixed type, total bilirubin >1.2 mg/dl, CA-19-9 >37 U/ml, tumor location in the pancreatic head, and tumor size >30 mm. Multivariate analysis showed that age, pancreatitis, mural nodule(s), and MPD diameter were independent predictors of invasive IPMN, and that all these parameters, plus elevated carbohydrate antigen-19-9 (CA-19-9), were independent predictors of malignant IPMN. A scoring system based on these five factors, each assigned 1 point, and with a cut-off of 3 points, could predict malignant IPMN with a sensitivity of 50.7% and a specificity of 90.1%. The 5-year survival rates of patients with benign and malignant IPMN were 95.0% and 64.0%, respectively. CONCLUSIONS: Our scoring system using five independent factors (age > or =60 years, history of pancreatitis, presence of mural nodule(s), elevated level of CA-19-9, and MPD diameter >6 mm) may be helpful for predicting malignancy and postoperative survival.

Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution.

BACKGROUND: Despite recent advances in laparoscopic pancreatic surgery, few studies have compared laparoscopic distal pancreatic resection (LDPR) with open distal pancreatic resection (ODPR). This study aimed to compare clinical outcomes for LDPR and ODPR performed at a single institution. METHODS: For this study, 93 patients with benign pancreatic disease underwent LDPR, and 35 patients with benign pancreatic disease underwent ODPR. Patient demographic characteristics, operative times, perioperative complications, length of hospital stay, and return to normal diet were compared retrospectively between the two groups. RESULTS: The LDPR and ODPR groups had the same demographic characteristics. The median operative time was 195 min in the LDPR group and 190 min in the ODPR group (p>0.05). The rate of spleen preservation was higher in the LDPR group (40.8%) than in the ODPR group (5.7%) (p<0.05) No operative mortality occurred in either group. The overall complication rate was 24.7% in the LDPR group and 29% in the ODPR group (p>0.05). The rate of pancreas-related complications was 11.8% in the LDPR group and 17.2% in the ODPR group (p>0.05). Pancreatic fistula developed in 8.6% of the LDPR group and in 14.3% of the ODPR group (p>0.05). Bowel movement return to normal and resumption of normal diet were achieved 2.8+/-1.3 days after the operation in the LDPR group and 4.5+/-1.6 days after the operation in the ODPR group (p<0.05). The median duration of hospital stay was 10 days for the LDPR group, which was significantly shorter than the 16 days for the ODPR group (p<0.01). CONCLUSION: The use of LDPR for benign lesions of the distal pancreas is feasible and safe. The LDPR procedure is associated with operative times and complication rates similar to those for ODPR, but LDPR has the advantages of an earlier return to normal bowel movements and normal diet and shorter hospital stays than ODPR.

Intraductal papillary mucinous neoplasm of the pancreas: clinical characteristics and treatment outcomes of 118 consecutive patients from a single center.

BACKGROUND/PURPOSE: Appropriate surgical treatment strategies based on clinicopathological findings are unavailable for intraductal papillary mucinous neoplasm (IPMN) of the pancreas. We investigated the clinical features of pancreatic IPMN in a single-center database in order to design an optimal surgical strategy. METHODS: The medical records of 118 consecutive patients who had undergone surgical resection between August 1994 and December 2004, in whom IPMN was histologically confirmed, were reviewed retrospectively for radiological and pathological findings. RESULTS: Most of the invasive carcinomas in these patients were detected as the main-duct type (88.5%). The type of tumor (main-duct type vs branched-duct type), the tumor size, and the dilated duct size were significant predictive factors associated with malignancy. The relative risk of malignancy was greatest at 13-mm or more ductal dilation in the main-duct type (Odds ratio, 4.1), at 35-mm or more tumor size (Odds ratio, 7.6), and for main-duct type (Odds ratio, 3.9). Major pancreatic resections such as total pancreatectomy and pancreatoduodenectomy were performed in 14.5% and 69% of the patients, respectively. There was a 19.5% rate of incomplete resection, with these patients having a positive resection margin. However, significant recurrence did not occur in patients with a benign IPMN lesion which remained at the resection margin. The overall postoperative survival rate at 5 years was 98.2% for benign IPMN and 65.3% for malignant IPMN. CONCLUSIONS: Function-preserving strategies, based on the clinical status of the patient, are necessary in order to avoid possible severe metabolic complications following extended pancreatectomy in patients with benign IPMN because of the low recurrence rate and good prognosis of this entity, irrespective of margin status.