Laparoscopic radical ‘no-touch’ left pancreatosplenectomy for pancreatic ductal adenocarcinoma: technique and results

Abstract

BackgroundLaparoscopic left pancreatectomy has been well described for benign pancreatic lesions, but its role in pancreatic adenocarcinoma remains open to debate. We report our results adopting a laparoscopic technique that obeys established oncologic principles of open distal pancreatosplenectomy.MethodsThis is a post hoc analysis of a prospectively kept database of 135 consecutive patients undergoing laparoscopic left pancreatectomy, performed across two sites in the UK and the Netherlands (07/2007–07/2015 Southampton and 10/2013–07/2015 Amsterdam). Primary outcomes were resection margin and lymph node retrieval. Secondary endpoints were other perioperative outcomes, including post-operative pancreatic fistula. Definition of radical resection was distance tumour to resection margin >1 mm. All patients underwent ‘laparoscopic radical left pancreatosplenectomy’ (LRLP) which involves ‘hanging’ the pancreas including Gerota’s fascia, followed by clockwise dissection, including formal lymphadenectomy.ResultsLRLP for pancreatic adenocarcinoma was performed in 25 patients. Seven of the 25 patients (28 %) had extended resections, including the adrenal gland (n = 3), duodenojejunal flexure (n = 2) or transverse mesocolon (n = 3). Mean age was 68 years (54–81). Conversion rate was 0 %, mean operative time 240 min and mean blood loss 340 ml. Median intensive/high care and hospital stay were 1 and 5 days, respectively. Clavien–Dindo score 3+ complication rate was 12 % and ISGPF grade B/C pancreatic fistula rate 28 %; 90-day (or in-hospital) mortality was 0 %. The pancreatic resection margin was clear in all patients, and the posterior margin was involved (<1 mm) in 6 patients, meaning an overall R0 resection rate of 76 %. No resection margin was microscopically involved. Median nodal sample was 15 nodes (3–26). With an average follow-up of 17.2 months, 1-year survival was 88 %.ConclusionsA standardised laparoscopic approach to pancreatic adenocarcinoma in the left pancreas can be adopted safely. Our study shows that these results can be reproduced across multiple sites using the same technique.

Multicentre observational cohort study of implementation and outcomes of laparoscopic distal pancreatectomy

“…Initially, the majority of those reports concerned only benign lesions and NETs; however, with growing experience, more data on the viability and oncological efficiency of the laparoscopic approach when dealing with malignant disease have been published. These promising results were confirmed recently by several meta‐analyses and the first RCT demonstrating the feasibility and safety of LDP compared with open distal pancreatectomy (ODP).…”

Can standardized pathology examination increase the lymph node yield following laparoscopic distal pancreatectomy for ductal adenocarcinoma?

“…9,18,19 As for LDP for PDAC, the median number of detected lymph nodes reportedly varies from 11 to 15. [21][22][23] However, none of these studies aimed at addressing whether it is the lymphadenectomy or the pathological examination protocol that is associated with the LNY. Presuming that standard lymphadenectomy at our center comprises all nodal stations mentioned in the ISGPS consensus statement, 15 and that therefore surgery is not the reason for a low LNY, this study investigated the potential impact of the pathology work-up on the number of lymph of nodes in the specimen.…”

Tumor manipulation during pancreatic resection for pancreatic cancer induces dissemination of tumor cells into the peritoneal cavity: a systematic review

“…The advantage of less tumor manipulation may also be held true in minimally invasive pancreatic resection, because of the inability to grasp or squeeze the tumor. 32,33 In colorectal cancer, 'no-touch' surgery has been investigated as a possible improved technique to reduce tumor manipulation. The main goal in 'notouch' surgery for colorectal cancer is to minimize dissemination of tumor cells from the primary tumor to the liver and other organs by the (portal) blood flow.…”