John A Stauffer, MD, Ross F Goldberg, MD, James M Parker, MD, Steven P Bowers, MD, C. Daniel Smith, MD, Horacio J Asbun, MD. Mayo Clinic, Florida
A vexing challenge of pancreatic surgery has been the development of pancreatic fistula. The rate of pancreatic fistula after traditional open distal or proximal pancreatic resection has been reported to be 13% in a recent review of nearly 4,000 patients. More recently, a minimally invasive approach to both distal and proximal pancreatic resection is being more frequently used. One of the advantages of a minimally invasive approach is less tissue trauma and a blunted inflammatory response. However, it has been postulated that a totally laparoscopic approach may have an increased rate of pancreatic fistula. The aim of our study was to determine the rate of pancreatic fistula for those patients who underwent totally laparoscopic non-robotic distal pancreatectomy (LDP) or pancreaticoduodenectomy (LPD) over a recent 1 year time period.
Methods and Procedures:
This is an IRB-approved retrospective cohort study from a single tertiary-carecenter. Between May 2009 and May 2010, sixty four patients underwent major pancreas resection by a single surgeon. Of these 64 patients, 41 underwent a totally laparoscopic approach (LDP and LPD) and comprise this study group. All patients undergoing LDP underwent staple transection at the neck or body of the pancreas using staple line reinforcement material. All patients undergoing LPD underwent reconstruction by laparoscopic duct-to-mucosa pancreaticojejunostomy over a stent. All patients followed a standardized postoperative pathway. Thirty-day or inpatient complications were graded according to the Clavien scale. Pancreatic fistula was graded according to international consensus guidelines.
There were 18 males and 23 females with a mean age of 61.3 (range 17-85). Eight patients were ASA class II and 33 patients were ASA class III. Mean BMI was 28.3 (range 15-42). Five patients had a prior history of pancreatitis, 2 with recent acute and 3 chronic. Indications for surgery were: pancreatic adenocarcinoma (7), IPMN (8), neuroendocrine (6), benign (5), ampullary adenocarcinoma (4), and miscellaneous neoplasm (11). Twenty eight patients underwent LDP and 13 LPD. Average estimated blood loss was 143 mL (range 2-600). Mean ICU stay and overall length of stay was 0.3 days (range 0-6) and 5 days (range 2-10) respectively. Overall morbidity was seen in 11 (27%) and there were no mortalities or reoperations. Clavien grade I, II, and IIIa complications were seen in 3 (7.3%), 4 (9.8%), and 4 (9.8%) patients respectively. Pancreatic fistulas were seen in 4 (9.8%) patients and were grade A in 2 (1 LDP and 1 LPD) who required prolonged drainage, grade B in 1 (LDP) who required percutaneous drainage, and grade C in 1 (LPD) who required multiple percutaneous drainage and rehospitalization.
Laparoscopic pancreatic resection can successfully be performed for a variety of indications and does not appear to have an increased rate of pancreatic fistula. Further refinements in technique may allow for more acceptance of a minimal access approach to pancreatic disease if other outcomes are also found to be comparable or improved when compared to open surgery.
Program Number: P357