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Laparoscopic Pancreatic Surgery
 

Laparoscopic Pancreatic Surgery

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  • IN 1911, Bernheim at The Johns Hopkins University performed the first

Laparoscopic Pancreatic Surgery Laparoscopic Pancreatic Surgery Presentation Transcript

  • LAPAROSCOPIC PANCREATIC SURGERY George Ferzli MD, FACS
  • ?
    • What is the current role of laparoscopic surgery with regard to pancreatic disease?
  • Role of laparoscopy DIAGNOSTIC
      • Tumor staging
    THERAPEUTIC
      • Curative
      • tumors
      • pseudocyst
      • pancreatic necrosis
      • - trauma
    Palliative
  • I- Diagnostic
  • “ In cases of ordinary exploratory operation for carcinoma, before having recourse to the usual large incision, the cystoscope is introduced through a very small and relatively unimportant incision, possibly made with cocaine, may reveal general metastases or a secondary nodule in the liver, thus rendering further procedures unnecessary and saving the patient a rather prolonged convalescence”. 1911 Bernheim: First laparoscopy for pancreatic cancer in the U.S.A. Bernheim B. Organoscopy: Cystoscopy of the abdominal cavity. Ann Surg 53:764-767,1911
    • Prospective study of 88 consecutive patients
    • Pancreatic and periampullary adenocarcinoma
    • Preoperative evaluation
      • CT scan with contrast 88 pts
      • MRI 20 pts
      • Laparoscopy 47 pts
      • Angiography 85 pts
    Preoperative Staging and Assessment of Resectability of Pancreatic Cancer Warshaw,A et al: Arch Surg 1990; 125:230-233
  • Results
    • Overall resectability 33/88 (38%)
    • Laparoscopy found metastatic disease when present in 22/23 patients (96%)
    • Laparoscopy found no metastatic disease in 24/24 patients (100%)
    Warshaw,A et al: Arch Surg 1990; 125:230-233
  • Conclusion
    • Laparoscopy is particularly sensitive for detecting small metastases (96%)
    • This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances
    Warshaw,A et al: Arch Surg 1990; 125:230-233
  • The Value of Minimal Access Surgery in the Staging of Patients with Potentially Resectable Peripancreatic Malignancies
    • 115 patients- radiologically resectable
    • Extensive laparoscopy performed
      • assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels
    Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • Unresectability
    • Metastases
      • hepatic, serosal, peritoneal
    • Extrapancreatic extension
      • mesocolic involvement
    • Nodal involvement
      • celiac or portal
    • Vascular invasion
      • celiac axis or hepatic artery
      • portal vein, SMV, SMA
    Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • No intraoperative or postoperative complications related to laparoscopy
    • 67 considered resectable  61 resected
    • Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient
    Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • Positive predictive index of 100%
    • Negative predictive index of 91%
    • Accuracy of 94%
    Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
    • Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy
    Conclusion Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  • Experience with staging laparoscopy in pancreatic malignancy Gastrointest Endo 1999; 49(4):498-503
    • 109 patients
    • CT scan revealed metastases in 10 patients
    • Laparoscopy diagnosed metastases in 29 more patients
    • At laparotomy, 6 more patients were identified as having metastatic disease
  • Results
    • Negative predictive value was 94%
    • Positive predictive value was 88%
  • Conclusion
    • In patients with a negative CT scan for metastasis, laparoscopic identification of metastasis avoided unnecessary laparotomy in 29 of 99 (29%) patients with pancreatic cancer. Staging laparoscopy is indicated in all cases of pancreatic malignancy before laparotomy.
  • Laparoscopic Ultrasound in the Staging of Pancreatic Cancer
    • Prospective evaluation of 90 patients
    • All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography
    • All patients had laparoscopy and laparoscopic ultrasound
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • Tumor location
      • Pancreatic head 64 (72%)
      • Pancreatic body 19 (21%)
      • Pancreatic tail 3 (3%)
      • Ampulla 4 (4%)
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)                                                                                         
  • Results Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2) ___ ___ 13 (14%) 8 (9%) EQUIVOCAL 50 (56%) 49 (54%) 41 (46%) 17 (19%) UNRESECTABLE ACTUAL LAP SONO LAP CT
  • LAPAROSCOPIC ULTRASOUND
    • SENSITIVITY 100%
    • SPECIFICITY 98%
    • ACCURACY 98%
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • Conclusion
    • The addition of laparoscopic ultrasound offers improved assessment and preoperative staging of pancreatic cancer.
    Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  • Summary
    • Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection
    • The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer
  • II- Therapeutic Laparoscopy
  • 1- LAPAROSCOPIC PANCREATICODUODENECTOMY
    • Gagner and Pomp – 1996
    • Strasberg, Drebin, and Soper – 1997
    • Cuschieri – 1998
    • CONCLUSION:
    • THE MAGNITUDE OF THE RECONSTRUCTION MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH
  • 2- MISCELLANEOUS PANCREATIC NEOPLASMS
  • Videolaparoscopic Resection of Insulinomas World Journal of Surgery Vol. 26, 2002 Laparoscopic Pancreatic Resection: Single Institution Experience of 19 Patients PETERSON, et al J Am Coll Surg 193(2),2001 Ultrasound Guided Laparoscopic Resection Of Pancreatic Islet Cell Tumors SPITZ, et al Surg Lap Endo Vol 10, 2000 DESCRIPTION STUDY
  •  
  • 3- Management of pancreatic pseudocyst and necrotizing pancreatitis
  • Laparoscopic Cholecystectomy and Acute Biliary Pancreatitis E Tang , NJ Soper , JJT Tate, W Uhl
    • 271 biliary pancreatitis, 22 % Ranson ≥ 3
    • Laparoscopic cholecystectomy 86 %
    • Early operation and Ranson ≥ 3 were associated with:
    • - more technical difficulties
    • - more conversions
    • - more CBD stones
  • Conclusions
    • Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS.
    • Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).
    • Timing of open or laparoscopic biliary surgery depends on AP severity
  • Urgent ERC/ES in Benign Acute Biliary Pancreatitis Neoptolemos Fan ERC Controls ERC Controls n (%) n (%) n (%) n (%) N patients 28 29 34 35 Complications - local 3 (11) 4 (14) 7 (21) 1 (3) - general 1 (4) 0 3 (9) 1 (3) Deaths 0 0 0 0
  • Conclusions
    • Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS.
    • Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).
    • Timing of open or laparoscopic biliary surgery depends on AP severity.
    • Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis
  • Surgery vs Endoscopic Sphincterotomy in Severe Cholangitis Endoscopy Surgery p Leese (non randomized) Mortality (%) 4.7 21.4 Lai (randomized) N patients 41 41 N (%) with Complications 14 (34) 27 (66) < 0.05 Deaths 4 (10) 13 (32) < 0.03
  • Conclusions
    • Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS.
    • Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).
    • Timing of open or laparoscopic biliary surgery depends on AP severity.
    • Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis.
    • Endoscopic sphincterotomy is indicated in Severe Cholangitis associated with Severe ABP
  • Pre- vs Postoperative ERCP in mild ABP Chang L,et al. Ann Surg 2000.
    • ERC + (LC+IOC) (LC+IOC) + ES
    • N of patients 30 29
    • ERC 30 7
    • CBD stones / ES 12 (40%) / 11 8 (28%) / 7
    • Overall stay (days) * 11.7 ± 6.1 9 ± 3.2
    • Costs ($) * 10,210 ± 3839 8,586 ± 3520
    • * p < 0.05
    Savings in terms of complications and costs can be expected if preoperative ERCPs are replaced by IOC ( Erickson 1995, Sees 1997, Barwood 2002)
  • Conclusions
    • Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS.
    • Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).
    • Timing of open or laparoscopic biliary surgery depends on AP severity.
    • Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis .
    • Endoscopic sphincterotomy is indicated in case of Severe Cholangitis associated with Severe ABP.
    • CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity 
  • Percutaneous and Laparoscopic Management of Infected Pancreatic Necrosis.
    • Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001
    • Number of patients 38
    • Complications Hemorrhage 4 Digestive Fistula 4 (10 % ) Pancreatic Fistula 4 (11 % ) Persisting Sepsis 5
    • Reoperations Laparoscopic 28 Arterial embolization 2 Laparotomy 9 (24 % )
    • Mortality 4 (11%)
  • Local Complications (%) Associated with Surgical Management of Infected Pancreatic Necrosis
    • Necrosectomy Retroper. Laparoscopy drainage lavage laparotomy Approach (95% CI)
    • N patients 256 166 134 60 38
    • Fistulas (%)
    • - Digestive 13 6 27 27 10 (0-20)
    • - Pancreatic 16 17 17 2 11 (2-22)
    • Hemorrhage 14 8 16 13 13 (2-23)
    • Mortality 42 18 21 28 11 (2-22)
  • Conclusions
    • Past pancreatitis is a poor indicator of CBDS.IOC is indicated regardless of the risk of CBDS.
    • Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).
    • Timing of open or laparoscopic biliary surgery depends on AP severity.
    • ES is NOT indicated in BENIGN ABP .
    • ES is indicated in case of Severe Cholangitis associated with Severe ABP.
    • CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity.
    • The l aparoscopic approach for necrotic collections is not a standard of care
  • Pancreatic pseudocysts
    • Non surgical techniques
      • Percutaneous aspiration-drainage
      • Endoscopic transgastric drainage
      • Endoscopic transpapillary procedures
    • Laparoscopic alternatives *
      • Pancreatic cystogastrostomy
      • Pancreatic cystojejunostomy
    • * Cuschieri, Gagner, Meltzer, Mouiel, Park, Way.
  • LAPAROSCOPIC INTERNAL DRAINAGE OF PSEUDOCYSTS Cystojejunostomy L. paracolic handsewn Palanivelu Cystojejunostomy Infracolic Cushieri Cystogastrostomy Stapled Intraluminal Litwin & Ross Cystogastrostomy Transgastric Handsewn Petelin
  • Therapeutic laparoscopy of the pancreas Park, A. Ann Surg 2002; 236(2):149-158
    • 28 patients underwent laparoscopic pancreatic pseudocystectomy
    • a. pancreatic cyst gastrostomy via the lesser sac approach
    • b. minilaparoscopic pancreatic cyst gastrostomy
    • c. intragastric pancreatic cyst gastrostomy
    • d. pancreatic cyst jejunostomy
  • Therapeutic laparoscopy of the pancreas
    • 25 patients underwent laparoscopic distal pancreatectomy
    • a. insulinoma
    • b. cystadenoma
    • c. chronic pancreatitis
    • d. simple cyst
  •  
  • 4- Pancreatic trauma
  • Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with Splenic Preservation
    • 10 yo handle bar injury
    • CT –free fluid and distal transection of the pancreas
    • Distal pancreatectomy with splenic preservation performed
    • Reg diet POD 2
    • D/C POD 3
    Ferzli,G et al; Surg Endosc July2001
  •  
  • III-Palliative Laparoscopy for Unresectable Pancreatic Cancer
  • Laparoscopic Gastro- and Hepaticojejunostomy
    • CASE-CONTROL STUDY
    • 14 patients – open palliation
    • 10 patients – laparoscopic palliation
    • 4 patients – diagnostic laparoscopy
    Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  • Results p<0.06 p<0.05 p<0.05 Rothlin,M et al;Surg Endosc (1999) 13:1065-1069 9 days 21 days HOSPITAL STAY 0% 29% MORTALITY 7% 43% MORBIDITY LAP (n=14) OPEN (n=14)
  • Conclusion
    • Laparoscopic palliation can reduce the three major drawbacks of open bypass surgery-i.e., high morbidity, high mortality, and long hospital stay.
    Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  • SUMMARY
    • Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer
    • Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma