Laparoscopic pancreaticoduodenectomy: experience of 22 cases.
BACKGROUND
Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center.


METHODS
From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed.


RESULTS
Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20).


CONCLUSIONS
The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.
Department of Laparoscopic and Robotic Surgery, Azienda Ospedaliera dei Colli-Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, Italy. francesco.corcione@ospedalemonaldi.it
Francesco
F
Corcione
Felice
F
Pirozzi
Diego
D
Cuccurullo
Domenico
D
Piccolboni
Valerio
V
Caracino
Francesco
F
Galante
Daniele
D
Cusano
Antonio
A
Sciuto
D000230:Adenocarcinoma / Q000601:surgery*; D000368:Aged; D061887:Conversion to Open Surgery / Q000706:statistics & numerical data; D004379:Duodenal Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000379:methods*; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D016896:Treatment Outcome