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Laparoscopic Pancreatic Surgery

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Laparoscopic Pancreatic Surgery

  1. 1. LAPAROSCOPIC PANCREATIC SURGERY George Ferzli MD, FACS
  2. 2. ? <ul><li>What is the current role of laparoscopic surgery with regard to pancreatic disease? </li></ul>
  3. 3. Role of laparoscopy DIAGNOSTIC <ul><ul><li>Tumor staging </li></ul></ul>THERAPEUTIC <ul><ul><li>Curative </li></ul></ul><ul><ul><li>tumors </li></ul></ul><ul><ul><li>pseudocyst </li></ul></ul><ul><ul><li>pancreatic necrosis </li></ul></ul><ul><ul><li>- trauma </li></ul></ul>Palliative
  4. 4. I- Diagnostic
  5. 5. “ 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
  6. 6. <ul><li>Prospective study of 88 consecutive patients </li></ul><ul><li>Pancreatic and periampullary adenocarcinoma </li></ul><ul><li>Preoperative evaluation </li></ul><ul><ul><li>CT scan with contrast 88 pts </li></ul></ul><ul><ul><li>MRI 20 pts </li></ul></ul><ul><ul><li>Laparoscopy 47 pts </li></ul></ul><ul><ul><li>Angiography 85 pts </li></ul></ul>Preoperative Staging and Assessment of Resectability of Pancreatic Cancer Warshaw,A et al: Arch Surg 1990; 125:230-233
  7. 7. Results <ul><li>Overall resectability 33/88 (38%) </li></ul><ul><li>Laparoscopy found metastatic disease when present in 22/23 patients (96%) </li></ul><ul><li>Laparoscopy found no metastatic disease in 24/24 patients (100%) </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
  8. 8. Conclusion <ul><li>Laparoscopy is particularly sensitive for detecting small metastases (96%) </li></ul><ul><li>This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances </li></ul>Warshaw,A et al: Arch Surg 1990; 125:230-233
  9. 9. The Value of Minimal Access Surgery in the Staging of Patients with Potentially Resectable Peripancreatic Malignancies <ul><li>115 patients- radiologically resectable </li></ul><ul><li>Extensive laparoscopy performed </li></ul><ul><ul><li>assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  10. 10. Unresectability <ul><li>Metastases </li></ul><ul><ul><li>hepatic, serosal, peritoneal </li></ul></ul><ul><li>Extrapancreatic extension </li></ul><ul><ul><li>mesocolic involvement </li></ul></ul><ul><li>Nodal involvement </li></ul><ul><ul><li>celiac or portal </li></ul></ul><ul><li>Vascular invasion </li></ul><ul><ul><li>celiac axis or hepatic artery </li></ul></ul><ul><ul><li>portal vein, SMV, SMA </li></ul></ul>Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  11. 11. <ul><li>No intraoperative or postoperative complications related to laparoscopy </li></ul><ul><li>67 considered resectable  61 resected </li></ul><ul><li>Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient </li></ul>Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  12. 12. <ul><li>Positive predictive index of 100% </li></ul><ul><li>Negative predictive index of 91% </li></ul><ul><li>Accuracy of 94% </li></ul>Results Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  13. 13. <ul><li>Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic malignancy </li></ul>Conclusion Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140
  14. 14. Experience with staging laparoscopy in pancreatic malignancy Gastrointest Endo 1999; 49(4):498-503 <ul><li>109 patients </li></ul><ul><li>CT scan revealed metastases in 10 patients </li></ul><ul><li>Laparoscopy diagnosed metastases in 29 more patients </li></ul><ul><li>At laparotomy, 6 more patients were identified as having metastatic disease </li></ul>
  15. 15. Results <ul><li>Negative predictive value was 94% </li></ul><ul><li>Positive predictive value was 88% </li></ul>
  16. 16. Conclusion <ul><li>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. </li></ul>
  17. 17. Laparoscopic Ultrasound in the Staging of Pancreatic Cancer <ul><li>Prospective evaluation of 90 patients </li></ul><ul><li>All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography </li></ul><ul><li>All patients had laparoscopy and laparoscopic ultrasound </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  18. 18. Tumor location <ul><li> </li></ul><ul><ul><li>Pancreatic head 64 (72%) </li></ul></ul><ul><ul><li>Pancreatic body 19 (21%) </li></ul></ul><ul><ul><li>Pancreatic tail 3 (3%) </li></ul></ul><ul><ul><li>Ampulla 4 (4%) </li></ul></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)                                                                                         
  19. 19. 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
  20. 20. LAPAROSCOPIC ULTRASOUND <ul><li>SENSITIVITY 100% </li></ul><ul><li>SPECIFICITY 98% </li></ul><ul><li>ACCURACY 98% </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  21. 21. Conclusion <ul><li>The addition of laparoscopic ultrasound offers improved assessment and preoperative staging of pancreatic cancer. </li></ul>Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)
  22. 22. Summary <ul><li>Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection </li></ul><ul><li>The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer </li></ul>
  23. 23. II- Therapeutic Laparoscopy
  24. 24. 1- LAPAROSCOPIC PANCREATICODUODENECTOMY <ul><li>Gagner and Pomp – 1996 </li></ul><ul><li>Strasberg, Drebin, and Soper – 1997 </li></ul><ul><li>Cuschieri – 1998 </li></ul><ul><li>CONCLUSION: </li></ul><ul><li>THE MAGNITUDE OF THE RECONSTRUCTION MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH </li></ul>
  25. 25. 2- MISCELLANEOUS PANCREATIC NEOPLASMS
  26. 26. 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
  27. 28. 3- Management of pancreatic pseudocyst and necrotizing pancreatitis
  28. 29. Laparoscopic Cholecystectomy and Acute Biliary Pancreatitis E Tang , NJ Soper , JJT Tate, W Uhl <ul><li>271 biliary pancreatitis, 22 % Ranson ≥ 3 </li></ul><ul><li>Laparoscopic cholecystectomy 86 % </li></ul><ul><li>Early operation and Ranson ≥ 3 were associated with: </li></ul><ul><li>- more technical difficulties </li></ul><ul><li>- more conversions </li></ul><ul><li>- more CBD stones </li></ul>
  29. 30. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity </li></ul>
  30. 31. 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
  31. 32. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis </li></ul>
  32. 33. 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
  33. 34. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis. </li></ul><ul><li>Endoscopic sphincterotomy is indicated in Severe Cholangitis associated with Severe ABP </li></ul>
  34. 35. Pre- vs Postoperative ERCP in mild ABP Chang L,et al. Ann Surg 2000. <ul><li> ERC + (LC+IOC) (LC+IOC) + ES </li></ul><ul><li>N of patients 30 29 </li></ul><ul><li>ERC 30 7 </li></ul><ul><li>CBD stones / ES 12 (40%) / 11 8 (28%) / 7 </li></ul><ul><li>Overall stay (days) * 11.7 ± 6.1 9 ± 3.2 </li></ul><ul><li>Costs ($) * 10,210 ± 3839 8,586 ± 3520 </li></ul><ul><li>* p < 0.05 </li></ul>Savings in terms of complications and costs can be expected if preoperative ERCPs are replaced by IOC ( Erickson 1995, Sees 1997, Barwood 2002)
  35. 36. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS. IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis . </li></ul><ul><li>Endoscopic sphincterotomy is indicated in case of Severe Cholangitis associated with Severe ABP. </li></ul><ul><li>CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity  </li></ul>
  36. 37. Percutaneous and Laparoscopic Management of Infected Pancreatic Necrosis. <ul><li>Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001 </li></ul><ul><li>Number of patients 38 </li></ul><ul><li>Complications Hemorrhage 4 Digestive Fistula 4 (10 % ) Pancreatic Fistula 4 (11 % ) Persisting Sepsis 5 </li></ul><ul><li>Reoperations Laparoscopic 28 Arterial embolization 2 Laparotomy 9 (24 % ) </li></ul><ul><li>Mortality 4 (11%) </li></ul>
  37. 38. Local Complications (%) Associated with Surgical Management of Infected Pancreatic Necrosis <ul><li>Necrosectomy Retroper. Laparoscopy drainage lavage laparotomy Approach (95% CI) </li></ul><ul><li>N patients 256 166 134 60 38 </li></ul><ul><li>Fistulas (%) </li></ul><ul><li>- Digestive 13 6 27 27 10 (0-20) </li></ul><ul><li>- Pancreatic 16 17 17 2 11 (2-22) </li></ul><ul><li>Hemorrhage 14 8 16 13 13 (2-23) </li></ul><ul><li>Mortality 42 18 21 28 11 (2-22) </li></ul>
  38. 39. Conclusions <ul><li>Past pancreatitis is a poor indicator of CBDS.IOC is indicated regardless of the risk of CBDS. </li></ul><ul><li>Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value). </li></ul><ul><li>Timing of open or laparoscopic biliary surgery depends on AP severity. </li></ul><ul><li>ES is NOT indicated in BENIGN ABP . </li></ul><ul><li>ES is indicated in case of Severe Cholangitis associated with Severe ABP. </li></ul><ul><li>CBD exploration is more efficient than ERC/ES. Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity. </li></ul><ul><li>The l aparoscopic approach for necrotic collections is not a standard of care </li></ul>
  39. 40. Pancreatic pseudocysts <ul><li>Non surgical techniques </li></ul><ul><ul><li>Percutaneous aspiration-drainage </li></ul></ul><ul><ul><li>Endoscopic transgastric drainage </li></ul></ul><ul><ul><li>Endoscopic transpapillary procedures </li></ul></ul><ul><li>Laparoscopic alternatives * </li></ul><ul><ul><li>Pancreatic cystogastrostomy </li></ul></ul><ul><ul><li>Pancreatic cystojejunostomy </li></ul></ul><ul><li>* Cuschieri, Gagner, Meltzer, Mouiel, Park, Way. </li></ul>
  40. 41. LAPAROSCOPIC INTERNAL DRAINAGE OF PSEUDOCYSTS Cystojejunostomy L. paracolic handsewn Palanivelu Cystojejunostomy Infracolic Cushieri Cystogastrostomy Stapled Intraluminal Litwin & Ross Cystogastrostomy Transgastric Handsewn Petelin
  41. 42. Therapeutic laparoscopy of the pancreas Park, A. Ann Surg 2002; 236(2):149-158 <ul><li>28 patients underwent laparoscopic pancreatic pseudocystectomy </li></ul><ul><li>a. pancreatic cyst gastrostomy via the lesser sac approach </li></ul><ul><li>b. minilaparoscopic pancreatic cyst gastrostomy </li></ul><ul><li>c. intragastric pancreatic cyst gastrostomy </li></ul><ul><li>d. pancreatic cyst jejunostomy </li></ul>
  42. 43. Therapeutic laparoscopy of the pancreas <ul><li>25 patients underwent laparoscopic distal pancreatectomy </li></ul><ul><li>a. insulinoma </li></ul><ul><li>b. cystadenoma </li></ul><ul><li>c. chronic pancreatitis </li></ul><ul><li>d. simple cyst </li></ul>
  43. 45. 4- Pancreatic trauma
  44. 46. Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with Splenic Preservation <ul><li>10 yo handle bar injury </li></ul><ul><li>CT –free fluid and distal transection of the pancreas </li></ul><ul><li>Distal pancreatectomy with splenic preservation performed </li></ul><ul><li>Reg diet POD 2 </li></ul><ul><li>D/C POD 3 </li></ul>Ferzli,G et al; Surg Endosc July2001
  45. 48. III-Palliative Laparoscopy for Unresectable Pancreatic Cancer
  46. 49. Laparoscopic Gastro- and Hepaticojejunostomy <ul><li>CASE-CONTROL STUDY </li></ul><ul><li>14 patients – open palliation </li></ul><ul><li>10 patients – laparoscopic palliation </li></ul><ul><li>4 patients – diagnostic laparoscopy </li></ul>Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  47. 50. 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)
  48. 51. Conclusion <ul><li>Laparoscopic palliation can reduce the three major drawbacks of open bypass surgery-i.e., high morbidity, high mortality, and long hospital stay. </li></ul>Rothlin,M et al;Surg Endosc (1999) 13:1065-1069
  49. 52. SUMMARY <ul><li>Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer </li></ul><ul><li>Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma </li></ul>

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