title: Total laparoscopic distal pancreatectomy: beyond selected patients.
abstract: Laparoscopic distal pancreatectomy (LDP) has emerged as the procedure of choice for selected patients. This study is to evaluate the feasibility of LDP and procedural outcomes in a series of consecutive nonselected patients. All patients undergoing distal pancreatectomy over 18 months  were identified from a prospectively maintained database, under institutional review board approval. A completely laparoscopic (non hand-assisted) procedure was performed using a 4-trocar technique. Conversion to an open procedure, operative time (OR), estimated blood loss (EBL), transfusion  requirements, postoperative length of stay (LOS), and complications were assessed. Sixteen patients were identified; 2/16 patients had undergone distal pancreatectomy as a component of another multiorgan open procedure, and were thus excluded. The remaining 14 patients had consented for LDP.  Conversion occurred in 4/14 cases. Converted patients trended towards increased OR, EBL, and LOS (P = not significant). No mortalities occurred, and overall morbidities included: pancreatic fistula (n = 2), splenic abscess (n = 1), and pneumonia (n = 1). LDP-splenectomy (n = 3/14) was  associated with both increased EBL (683 mL ± 388 vs 168 ± 141, P < 0.002) and increased transfusion rate (3/3 vs 3/11, P = 0.05), as compared with LDP-splenic preservation. LDP with splenic artery preservation (LDP-SAP) was completed in 7 of 14  patients, with less OR (2 hours 29 minutes ± 53 minutes vs 3 hours 40 minutes ± 1 hour, P < 0.05), a decreased transfusion rate (14% vs 71%, P = 0.05), and decreased LOS (2.8 days vs 6.8 days, P = 0.002) compared with LDP without SAP.  Pathology was intraductal papillary mucinous neoplasm (IPMN) (n = 5), ductal carcinoma (n = 3), high grade dysphasia (n = 2), neuroendocrine tumor (n = 2), and pancreatitis (n = 2). Patients undergoing LDP-SAP demonstrated superior peri-procedural outcomes. This series of nonselected consecutive  patients supports that LDP is technically feasible with a comparable procedural outcome to the selected-patient literature, suggesting potentially expanded indications for LDP.
authors.affiliation: Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA.
authors.forename: Cherif
authors.initials: C
authors.lastname: Boutros
authors.forename: Kristin
authors.initials: K
authors.lastname: Ryan
authors.forename: Steven
authors.initials: S
authors.lastname: Katz
authors.forename: N Joseph
authors.initials: NJ
authors.lastname: Espat
authors.forename: Ponnandai
authors.initials: P
authors.lastname: Somasundar
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D010535:Laparoscopy; D007902:Length of Stay / Q000639:trends; D008297:Male; D010180:Pancreatectomy / Q000379:methods*; D010182:Pancreatic Diseases / Q000601:surgery*; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology