Pancreatic cancer is one of the most aggressive malignancies associated with extremely poor 5-year survival rate (6–7%) . Since the tumor remains asymptomatic in the early stage, only 15% of patients have resectable disease at diagnosis.
In the remaining cases, local infiltration, invasion of surrounding vessels and the presence of early distant metastases are considered the major causes precluding radical surgical treatment.
Surgery remains the only option to cure pancreatic malignancies.
Since first reports by Walther Kausch in 1912 and Allen Whipple in 1935, the operative technique and perioperative care have been gradually improved.
Post-operative mortality has decreased from 30% in the early years to 3–5%, as shown in the most recent analyses. Nevertheless, pancreatic cancer surgery is still associated with relatively high morbidity of approximately 40%.
Laparoscopic distal pancreatectomy
Surgery of the body and the tail of the pancreas and pancreatic head surgery are different for many reasons.
Firstly, the majority of LDP pancreatectomies are performed for benign tumors, and in these cases, the procedure itself is less extensive, especially in spleen-preserving cases. Because there are no gastrointestinal anastomoses— including pancreatic anastomosis—it literally eliminates one of the major causes of morbidity.
Looking into results, several potential benefits of minimally invasive access were observed: reduced blood loss, lower morbidity in most of previous meta-analyses (OR 0.71–0.92) and shortened length of hospital stay (by 2.7 up to 12.3 days).
Based on the available literature, LPD can be certainly offered to patients with benign lesions and, in the hands of an experienced surgeon, may prove to be beneficial in other cases.
In cancer patients, LEOPARD-1 concluded that in patients with left-sided pancreatic tumors confined to the pancreas, MIDP reduces time to functional recovery compared with ODP. Complications were not reduced, less delayed gastric emptying and better quality of life with no increasing costs.
Pancreatoduodenectomy is the only potential curative treatment for patients presenting periampullary cancer and premalignant tumors.
The conventional operation for pancreatic cancer of the head or uncinate process is pancreaticoduodenectomy. Conventional pancreaticoduodenectomy (ie, Whipple procedure) involves removal of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder, and a partial gastrectomy.
Modifications of the conventional pancreaticoduodenectomy procedure have been developed in an attempt to improve outcomes or minimize the morbidity associated with the operation. These include:
Pylorus-preserving pancreaticoduodenectomy preserves the gastric antrum, pylorus, and proximal 3 to 6 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal continuity. The procedure may decrease the incidence of postoperative dumping, marginal ulceration, and bile reflux gastritis that can occur in some patients undergoing partial gastrectomy. The available data suggest that, for suitable cases, perioperative morbidity and mortality and long-term survival are not adversely affected using a pylorus-preserving technique.
Subtotal stomach-preserving pancreaticoduodenectomy
Subtotal stomach-preserving pancreaticoduodenectomy aims to preserve as much stomach as possible while minimizing problems related to delayed gastric emptying that are associated with preserving the pyloric ring in the face of a loss of vagal innervation.
Pancreatoduodenectomy is associated with high morbidity rates and a strong volume-outcome relationship.
Its prognosis remains poor even with pancreaticoduodenectomy with surgically negative margins.
It is associated with significant postoperative morbidity rates, ranging from 30% to 60%.
Major postoperative complications include: pancreatic leak or fistula, intraabdominal abscess, bile leak, postoperative hemorrhage, delayed gastric emptying, and complications related to the surgical site.
Minimally invasive pancreatoduodenectomy
Minimally invasive pancreatoduodenectomy (MIPD) was introduced in order to reduce morbidity and enhance postoperative recovery compared with open pancreatoduodenectomy (OPD).
MIPD has been associated with increased mortality compared with OPD, but this results are obtained in centers performing fewer than 10 MIPDs annually.
As improved outcomes have been observed in centers performing more than 40 OPDs annually this could indicate that the optimal cut-off for MIPD is also higher.
MIPD VS OPD
In the latest review in Annals of Surgery, Klompmaker, S et al compared open pancreatoduodenectomy (OPD) with Minimally invasive pancreatoduodenectomy (MIPD):
MIPD had longer operative times.
MIPD had more pancreatogastrostomies.
MIPD presented more grade B/C POPF (postoperative pancreatic fistula).
Similar rates of endoscopic reintervention, percutaneous catheter drainage, intensive care admission and reoperation.
No differences in routine intraoperative drain placement.
Similar morbidity and mortality rates.
MIPD presented longer length of hospital stay (similar rates if POPF patients were excluded)
Minimally invasive pancreatic surgery is feasible by experienced surgeons.
For body and tail tumors, it provides reduced blood loss, lower morbidity, shortened length of hospital stay but its oncological benefits need to be analyzed in a long-term period.
MIPD vs OPD found no differences in 30-day mortality but increased operative time for MIPD
Dedicated training programs and total/annual procedure-specific case volumes are the 2 major determinants for MIPD.
More prospective clinical trials need to be performed by experienced centers and surgeons before the true impact of MIPD can be established