Laparoscopic Pancreaticoduodenectomy: Outcomes and Experience of 550 Patients in a Single Institution

Abstract

Introduction

Laparoscopic pancreaticoduodenectomy (LPD) is one of the most technically challenging surgical procedures, involving complicated dissection and reconstruction. Recently, enthusiasm for performing this procedure has increased; however, concerns have been raised regarding its perioperative and oncologic outcomes.

Methods

We retrospectively reviewed patients who underwent LPD between 2010 and 2019 at our institution. We analyzed perioperative and oncologic outcomes of LPD, risk factors associated with complications, and the learning curve.

Results

550 patients underwent LPD, including 473 standard LPD and 77 LPD with vascular resection. Of these, 38.5% experienced complications. Pancreatic fistula occurred in 24% of patients. Five patients died within 90 days. No significant differences were observed in terms of complications or 90-day mortality between patients who underwent LPD with vascular resection versus standard LPD. Patients with pancreatic cancer had the shortest median survival time (20 months); patients with duodenal or papillary cancer had the longest median survival time (50 months). Pancreatic cancer, American Society of Anesthesiologists (ASA) score, and operative time were risk factors associated with complications, and previous abdominal surgery, ASA score, and body mass index were risk factors associated with severe complications. Finally, surgeons who performed standard LPD had a learning period of 47 procedures, whereas surgeons who performed LPD with vascular resection were proficient after having performed 200 standard LPD procedures.

Conclusions

LPD is a safe, feasible, and oncologically acceptable procedure when performed in a high-volume center. Performance of LPD should follow a step-by-step principle because of the long and steep learning curve.

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Abbreviations

BMI:

Body mass index

DGE:

Delayed gastric emptying

LPD:

Laparoscopic pancreaticoduodenectomy

OPD:

Open pancreaticoduodenectomy

OT:

Operative time

POPF:

Postoperative pancreatic fistula

PPH:

Postpancreatic hemorrhage

References

  1. 1.

    Gagner M, Pomp A. Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc. 1994;8(5):408–410.

  2. 2.

    Pugliese R, Scandroglio I, Sansonna F, et al. Laparoscopic pancreaticoduodenectomy: a retrospective review of 19 cases. Surgical laparoscopy, endoscopy & percutaneous techniques. 2008;18(1):13–18.

  3. 3.

    Palanivelu C, Jani K, Senthilnathan P, et al. Laparoscopic pancreaticoduodenectomy: technique and outcomes. Journal of the American College of Surgeons. 2007;205(2):222–230.

  4. 4.

    Han SH, Kang CM, Hwang HK, et al. The Yonsei experience of 104 laparoscopic pancreaticoduodenectomies: a propensity score-matched analysis with open pancreaticoduodenectomy. Surgical endoscopy. 2020;34(4):1658–1664.

  5. 5.

    Poves I, Burdio F, Morató O, et al. Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial. Annals of surgery. 2018;268(5):731–739.

  6. 6.

    Khatkov I, Izrailov R, Tyutyunnik P, et al. One hundred and forty five total laparoscopic pancreatoduodenectomies: A single centre experience. Pancreatology. 2017;17(6):936–942.

  7. 7.

    Palanivelu C, Senthilnathan P, Sabnis SC, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. The British journal of surgery. 2017;104(11):1443–1450.

  8. 8.

    Ausania F, Landi F, Martínez-Pérez A, et al. A meta-analysis of randomized controlled trials comparing laparoscopic vs open pancreaticoduodenectomy. HPB. 2019;21(12):1613–1620.

  9. 9.

    van Hilst J, de Rooij T, Bosscha K, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. The Lancet Gastroenterology & Hepatology. 2019;4(3):199–207.

  10. 10.

    Adam MA, Thomas S, Youngwirth L, et al. Defining a Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy in the United States. JAMA surgery. 2017;152(4):336–342.

  11. 11.

    Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Annals of surgery. 2009;250(2):187–196.

  12. 12.

    Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584–591.

  13. 13.

    Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142(1):20–25.

  14. 14.

    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(5):761–768.

  15. 15.

    Cai Y, Gao P, Li Y, et al. Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction: anterior superior mesenteric artery first approach. Surg Endosc. 2018;32(10):4209–4215.

    PubMed  Article  Google Scholar 

  16. 16.

    Cai Y, Chen S, Peng B. Two-surgeon Model in Laparoscopic Pancreaticoduodenectomy. Surg Laparosc Endosc Percutan Tech. 2019;29(4):275–279.

  17. 17.

    Wang X, Cai Y, Zhao W, et al. Laparoscopic pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition graft: Case series. Medicine (Baltimore). Jan 2019;98(3):e14204.

    PubMed  PubMed Central  Article  Google Scholar 

  18. 18.

    Broering DC, Berardi G, El Sheikh Y, et al. Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation. Annals of surgery. 2020;271(3):542–548.

  19. 19.

    Muggeo VM. Estimating regression models with unknown break-points. Statistics in medicine. 2003;22(19):3055–3071.

    Article  Google Scholar 

  20. 20.

    Wang M, Peng B, Liu J, et al. Practice Patterns and Perioperative Outcomes of Laparoscopic Pancreaticoduodenectomy in China: A Retrospective Multicenter Analysis of 1029 Patients. Ann Surg. (2019). https://doi.org/10.1097/SLA.0000000000003190.

  21. 21.

    Song KB, Kim SC, Lee W, et al. Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc. (2019). https://doi.org/10.1007/s00464-019-06913-9.

  22. 22.

    Adam MA, Choudhury K, Dinan MA, et al. Minimally Invasive Versus Open Pancreaticoduodenectomy for Cancer: Practice Patterns and Short-term Outcomes Among 7061 Patients. Annals of surgery. 2015;262(2):372–377.

  23. 23.

    Gumbs AA, Rodriguez Rivera AM, Milone L, et al. Laparoscopic pancreatoduodenectomy: a review of 285 published cases. Ann Surg Oncol. May 2011;18(5):1335–1341.

    PubMed  Article  Google Scholar 

  24. 24.

    Torphy RJ, Friedman C, Halpern A, et al. Comparing Short-term and Oncologic Outcomes of Minimally Invasive Versus Open Pancreaticoduodenectomy Across Low and High Volume Centers. Annals of surgery. 2019;270(6):1147–1155.

  25. 25.

    Croome KP, Farnell MB, Que FG, et al. Pancreaticoduodenectomy with major vascular resection: a comparison of laparoscopic versus open approaches. J. Gastrointest. Surg. 2015;19(1):189-194.

  26. 26.

    Khatkov I, Izrailov R, Khisamov A, et al. Superior mesenteric-portal vein resection during laparoscopic pancreatoduodenectomy. Surg Endosc. 2017;31(3):1488–1495.

    PubMed  Article  Google Scholar 

  27. 27.

    Palanisamy S, Deuri B, Naidu S, et al. Major venous resection and reconstruction using a minimally invasive approach during laparoscopic pancreaticoduodenectomy: One step forward. Asian J Endosc Surg. 2015;8(4):468–472.

    PubMed  Article  Google Scholar 

  28. 28.

    Dokmak S, Chérif R, Duquesne I, et al. Laparoscopic Pancreaticoduodenectomy with Reconstruction of the Portal Vein with the Parietal Peritoneum. Ann. Surg. Oncol. 2016;23(8):2664.

    PubMed  Article  Google Scholar 

  29. 29.

    Boggi U, Amorese G, Vistoli F, et al. Laparoscopic pancreaticoduodenectomy: a systematic literature review. Surgical endoscopy. 2015;29(1):9–23.

  30. 30.

    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.

  31. 31.

    Chen K, Zhou Y, Jin W, et al. Laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic outcomes and long-term survival. Surgical endoscopy. 2020;34(5):1948–1958.

  32. 32.

    Shubert CR, Kendrick ML, Thomsen KM, et al. Identification of risk categories for in pancreaticoduodenectomy based on diagnosis. HPB. 2015;17(5):428–437.

    Article  Google Scholar 

  33. 33.

    Hester CA, Nassour I, Christie A, et al. Predictors and outcomes of converted minimally invasive pancreaticoduodenectomy: a propensity score matched analysis. Surgical endoscopy. 2020;34(2):544–550.

  34. 34.

    Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. Journal of the American College of Surgeons. 2013;217(5):833-842.e831–833.

  35. 35.

    Wiltberger G, Muhl B, Benzing C, et al. Preoperative risk stratification for major complications following pancreaticoduodenectomy: Identification of high-risk patients. International journal of surgery (London, England). 2016;31:33–39.

  36. 36.

    Nagakawa Y, Nakamura Y, Honda G, et al. Learning curve and surgical factors influencing the surgical outcomes during the initial experience with laparoscopic pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2018;25(11):498–507.

    PubMed  Article  Google Scholar 

  37. 37.

    Cai Y, Luo H, Li Y, et al. A novel technique of pancreaticojejunostomy for laparoscopic pancreaticoduodenectomy. Surg Endosc. 2019;33(5):1572–1577.

    PubMed  Article  Google Scholar 

  38. 38.

    Hogg ME, Besselink MG, Clavien PA, et al. Training in Minimally Invasive Pancreatic Resections: a paradigm shift away from "See one, Do one, Teach one". HPB. 2017;19(3):234–245.

    Article  Google Scholar 

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Correspondence to Bing Peng MD, FACS.

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This study was supported by the National Institutes of Health of China (W2017ZWS07) and Science and Technology Department of Sichuan Province (2018KZ0021).

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Wang, X., Cai, Y., Jiang, J. et al. Laparoscopic Pancreaticoduodenectomy: Outcomes and Experience of 550 Patients in a Single Institution. Ann Surg Oncol 27, 4562–4573 (2020). https://doi.org/10.1245/s10434-020-08533-3

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