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Objective: The aim of this study was to compare oncological outcomes after minimally invasive distal pancreatectomy (MIDP) with open distal pancreatectomy (ODP) in patients with pancreatic ductal adenocarcinoma (PDAC)., Background: Cohort studies have suggested superior short-term outcomes of MIDP vs. ODP. Recent international surveys, however, revealed that surgeons have concerns about the oncological outcomes of MIDP for PDAC., Methods: This is a pan-European propensity score matched study including patients who underwent MIDP (laparoscopic or robot-assisted) or ODP for PDAC between January 1, 2007 and July 1, 2015. MIDP patients were matched to ODP patients in a 1:1 ratio. Main outcomes were radical (R0) resection, lymph node retrieval, and survival., Results: In total, 1212 patients were included from 34 centers in 11 countries. Of 356 (29%) MIDP patients, 340 could be matched. After matching, the MIDP conversion rate was 19% (n = 62). Median blood loss [200 mL (60-400) vs 300 mL (150-500), P = 0.001] and hospital stay [8 (6-12) vs 9 (7-14) days, P < 0.001] were lower after MIDP. Clavien-Dindo grade ≥3 complications (18% vs 21%, P = 0.431) and 90-day mortality (2% vs 3%, P > 0.99) were comparable for MIDP and ODP, respectively. R0 resection rate was higher (67% vs 58%, P = 0.019), whereas Gerota's fascia resection (31% vs 60%, P < 0.001) and lymph node retrieval [14 (8-22) vs 22 (14-31), P < 0.001] were lower after MIDP. Median overall survival was 28 [95% confidence interval (CI), 22-34] versus 31 (95% CI, 26-36) months (P = 0.929)., Conclusions: Comparable survival was seen after MIDP and ODP for PDAC, but the opposing differences in R0 resection rate, resection of Gerota's fascia, and lymph node retrieval strengthen the need for a randomized trial to confirm the oncological safety of MIDP.

Background: Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients., Methods: An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey., Results: LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe., Conclusions: LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.

Background: Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No international consensus definition or grading system of chyle leak currently is available., Methods: The International Study Group on Pancreatic Surgery, an international panel of pancreatic surgeons working in well-known, high-volume centers, reviewed the literature and worked together to establish a consensus on the definition and classification of chyle leak after pancreatic operation., Results: Chyle leak was defined as output of milky-colored fluid from a drain, drain site, or wound on or after postoperative day 3, with a triglyceride content ≥110 mg/dL (≥1.2 mmol/L). Three different grades of severity were defined according to the management needed: grade A, no specific intervention other than oral dietary restrictions; grade B, prolongation of hospital stay, nasoenteral nutrition with dietary restriction, total parenteral nutrition, octreotide, maintenance of surgical drains, or placement of new percutaneous drains; and grade C, need for other more invasive in-hospital treatment, intensive care unit admission, or mortality., Conclusion: This classification and grading system for chyle leak after pancreatic resection allows for comparison of outcomes between series. As with the other the International Study Group on Pancreatic Surgery consensus statements, this classification should facilitate communication and evaluation of different approaches to the prevention and treatment of this complication., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Minimally invasive (MI) pancreatic surgery appears to be gaining popularity, but its implementation throughout Europe and the opinions regarding its use in pancreatic cancer patients are unknown., Methods: A 30-question survey was sent between June and December 2014 to pancreatic surgeons of the European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association and 5 European national pancreatic societies. Incomplete responses were excluded., Results: In total, 237 pancreatic surgeons responded. After excluding 34 incomplete responses, 203 responses from 27 European countries were included. 164 (81%) surgeons were employed at a university hospital, 184 (91%) performed advanced MI surgery and 148 (73%) performed MI distal pancreatectomy. MI pancreatoduodenectomy was performed by 42 (21%) surgeons, whereas 9 (4.4%) surgeons had performed more than 10 procedures. Robot-assisted MI pancreatic surgery was performed by 28 (14%) surgeons. 63 (31%) surgeons expected MI distal pancreatectomy for cancer to be inferior to open distal pancreatectomy concerning oncological outcomes. 151 (74%) surgeons expected to benefit from training in MI distal pancreatectomy and 149 (73%) were willing to participate in a randomized trial on this topic., Conclusions: MI distal pancreatectomy is a common procedure, although its use for cancer is still disputed. MI pancreatoduodenectomy is still an uncommon procedure. Specific training and a randomized trial regarding MI pancreatic cancer surgery are welcomed., (Copyright © 2015 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Laparoscopic distal pancreatectomy (LDP) for large pancreatic tumors may require prolonged dissection, and this could be associated with increased operative time and intraoperative complications., Methods: From a total cohort of 190 consecutive patients undergoing LDP, 18 patients were found to have pancreatic tumors >5 cm and were included in the retrospective study of prospectively collected data. Three techniques were used to approach the splenic vessels: the superior pancreatic, the inferior supracolic and post-pancreatic transection., Results: Of these 18 patients, 13 were women and 5 were men, the median age was 68 years and their median tumor size 7 cm. Exocrine pancreatic malignancy was diagnosed in 8 patients, 6 patients had neuroendocrine pancreatic tumors and 4 patients cystic neoplasm. The median number of resected nodes was 14. R1 resections for exocrine pancreatic malignancies were found in 50% of patients. Morbidity (grade >II) was found in 16.6% of patients and 30 days mortality in 1 patient. Overall median survival was 50 months and 29 months for patients with exocrine pancreatic malignancies., Conclusions: LDP for large tumors, while technically demanding, is possible without additional morbidity and did not compromise short- and long-term oncological outcomes., (© 2016 S. Karger AG, Basel.)

Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed., (Copyright © 2014 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The lymph node (Ln) status of patients with resectable pancreatic ductal adenocarcinoma is an important predictor of survival. The survival benefit of extended lymphadenectomy during pancreatectomy is, however, disputed, and there is no true definition of the optimal extent of the lymphadenectomy. The aim of this study was to formulate a definition for standard lymphadenectomy during pancreatectomy., Methods: During a consensus meeting of the International Study Group on Pancreatic Surgery, pancreatic surgeons formulated a consensus statement based on available literature and their experience., Results: The nomenclature of the Japanese Pancreas Society was accepted by all participants. Extended lymphadenectomy during pancreatoduodenectomy with resection of Ln's along the left side of the superior mesenteric artery (SMA) and around the celiac trunk, splenic artery, or left gastric artery showed no survival benefit compared with a standard lymphadenectomy. No level I evidence was available on prognostic impact of positive para-aortic Ln's. Consensus was reached on selectively removing suspected Ln's outside the resection area for frozen section. No consensus was reached on continuing or terminating resection in cases where these nodes were positive., Conclusion: Extended lymphadenectomy cannot be recommended. Standard lymphadenectomy for pancreatoduodenectomy should strive to resect Ln stations no. 5, 6, 8a, 12b1, 12b2, 12c, 13a, 13b, 14a, 14b, 17a, and 17b. For cancers of the body and tail of the pancreas, removal of stations 10, 11, and 18 is standard. Furthermore, lymphadenectomy is important for adequate nodal staging. Both pancreatic resection in relatively fit patients or nonresectional palliative treatment were accepted as acceptable treatment in cases of positive Ln's outside the resection plane. This consensus statement could serve as a guide for surgeons and researchers in future directives and new clinical studies., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: To compare preservation with the division of the splenic vessels in the surgical management of laparoscopic spleen-preserving distal pancreatectomy., Design: Bicentric retrospective study., Setting: Prospectively maintained databases., Patients: Between January 1997 and January 2011, 140 patients who underwent laparoscopic spleen-preserving distal pancreatectomy for benign or lowgrade malignant tumors in the body/tail of the pancreas were included. Patients treated with the attempted splenic vessel preservation were compared with patients treated with the attempted division of the splenic vessels (Warshaw technique)., Main Outcome Measures: Operative outcomes and postoperative morbidity were evaluated., Results: The outcomes of 55 patients in the splenic vessel preservation group were compared with those of 85 patients in the Warshaw technique group. The clinical characteristics were similar in both groups, except for tumor size, which was significantly greater in the Warshaw technique group (33.6 vs. 42.5 mm; P=.001). The mean operative time, mean blood loss, and rate of conversion to the open procedure did not differ between the 2 groups. The rate of successful spleen preservation was significantly improved following the splenic vessel preservation technique (96.4% vs. 84.7%; P=.03). Complications related to the spleen only occurred in the Warshaw technique group (0% vs. 10.5%; P=.03), requiring a splenectomy in 4 patients (4.7%). The mean length of stay was shorter in the splenic vessel preservation group (8.2 vs. 10.5 days; P=.01)., Conclusions: The short-term benefits associated with the preservation of the splenic vessels should lead to an increased preference for this technique in selected patients undergoing laparoscopic spleen-preserving distal pancreatectomy for benign or low-grade malignant tumors in the body/tail of the pancreas.

Background: Non-functional endocrine pancreatic tumours (NPT) of more than 2 cm have an increased risk of malignancy. The aim of the present study was: (i) to define the guidelines for laparoscopic enucleation (LapEn) in patients with a non-functional NPT ≤3 cm in diameter; (ii) to evaluate pancreas-related complications; and (iii) to present the long-term outcome., Methods: Between April 1998 and September 2010, 30 consecutive patients underwent laparoscopic surgery for a non-functional NPT (median age 56.5 years, range 44-83). Only 13 patients with tumours ≤3 cm in size underwent LapEn. Local lymph node dissection to exclude lymph node involvement was performed in all patients., Results: The median tumour size, operative time and blood loss were 2.8 cm (range 2.8-3), 130 min (range 90-280) and 220 ml (range 120-300), respectively. A pancreatic fistula occurred in five patients: International Study Group of Pancreatic Fistula (ISGPF) A in two patients and ISGPF B in three patients. The median follow-up was 48 months (12-144). Three patients with well-differentiated carcinoma are free of disease 2, 3 and 4 years after LapEn and a regional lymphadenectomy. One patient, 5 years after a LapEn, presented with lymph node and liver metastases., Conclusions: The present study confirms the technical feasibility and acceptable morbidity associated with LapEn. Intra-operative lymph node sampling and frozen-section examination should be performed at the time of LapEn; when a malignancy is confirmed, oncologically appropriate lymph node dissection should be performed., (© 2012 International Hepato-Pancreato-Biliary Association.)

Background:   Regular follow-up and monitoring of intraductal papillary mucinous neoplasms (IPMN) is important as there is a risk of recurrence in both the non-invasive and invasive IPMN., Methods:   Three patients developed pancreatic remnant recurrence after a pancreatico-duodenectomy for IPMN. Pancreatico-gastrostomy anastomosis was performed in all patients. Long-term follow-up was performed with radiographical surveillance and by endoscopic gastroscopy., Results:   Magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS) revealed in one patient, 2 years after surgery, a 3-cm mass at the site of the anastomosis and dilatation of the Wirsung duct >6 mm in two other patients (2 and 3 years after surgery, respectively). The diagnosis of recurrence was confirmed endoscopically by the presence of a large amount of mucin at the anastomotic site. Cytological examination revealed moderate dysplasia. Opacification of the Wirsung duct after endoscopic retrograde cholangiopancreatography (ERCP) was only possible in one patient in whom an irregular stenosis of the duct was observed., Conclusions:   Long-term follow-up of the pancreatic remnant after pancreato-duodenectomy for IPMN is better achieved with pancreatico-gastrostomy anastomosis., (© 2011 International Hepato-Pancreato-Biliary Association.)

Since the first reports with laparoscopic resection of islet cell tumors in 1996, the experience worldwide is still limited, with only short-term outcomes available. Some have suggested that a malignant tumor is a contraindication to laparoscopic resection. Aim The aim of this study was to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with functioning, nonfunctioning, or overt malignant pancreatic neuroendocrine tumor (PNT). To our knowledge this is the largest single-institution series on this subject to date. Patients and methods A total of 49 consecutive patients (43 women, 6 men; mean age 58 years, range 22-83 years) underwent laparoscopic pancreatic surgery (LPS) from April 1998 to June 2007. Preoperative localization was done by computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and Octreoscan imaging. Other than 9 PNTs localized in the head of the pancreas, all tumors were located in the left pancreas. Malignancy was diagnosed based on the presence of lymph nodes or liver metastasis. There were 33 patients with functioning tumors: 4 with gastrinomas (mean size 1.2 cm), 1 with a glucagonoma (4 cm), 3 with vipomas (3.2 cm), 2 with carcinoids (5.2 cm), 20 with sporadic insulinomas (1.4 cm), 2 with insulinoma/multiple endocrine neoplasia type 1 (MEN-1) (4.4 cm), and 1 with a malignant insulinoma (13 cm). Sixteen patients had a nonfunctioning tumor (mean size 5 cm). The following techniques were performed: laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP), laparoscopic distal pancreatectomy with splenectomy (Lap SxDP) and laparoscopic enucleation (Lap En)/laparoscopic excision (Lap E). Lymph node dissection was performed when malignancy was suspected (Strasberg s technique). Evaluation criteria included operative and postoperative factors, pathologic data including R0 or R1 resection (the pancreatic transection margin and all transection margins on the specimen were inked). Long-term outcomes were analyzed by tumor recurrence and patient survival. Results Four cases (8.2%) were converted to open surgery. Overall, Lap SPDP, Lap SxDP, and Lap En/Lap E were performed in 15 (33.3%), 8 (17.8%), and 22 (48.9%) patients, respectively. The operative time and blood loss was significantly lower in the Lap En group compared with the other laparoscopic techniques. The group of patients with malignant tumors undergoing Lap SxDP had a longer operating time and greater blood loss compared with the other distal pancreatectomy (Lap DP) techniques. Overall, the postoperative complications were significantly higher in the Lap En group (42.8%) than in the Lap DP (Lap SPDP+Lap SxDP) group (22%). These complications were mainly pancreatic fistula: 8.7% after Lap DP and 38% after Lap En. The overall morbidity was significantly higher after Lap SPDP (26.7%) than after Lap SxDP (12.5%) owing to the occurrence of splenic complications in the Lap SPDP group without splenic vessel preservation two of seven (28.5%). The means and ranges of hospital stay after Lap SPDP, Lap SxDP, and Lap En/Lap E were 5.9 (5-14), 7.5 (5-12), and 5.5 (5-7) days, respectively (NS). Pathology examination of the specimen showed R0 resection in all patients with malignant PNT. The mean time to resumption of previous activities for patients undergoing Lap DP or Lap En was 3 weeks. There were no postoperative (30 days) or hospital deaths. Conclusions This series demonstrates that LPS is feasible and safe in benign-appearing and malignant neuroendocrine pancreatic tumors (NEPTs). The benefits of minimally invasive surgery were manifest in the short hospital stay and acceptable pancreas-related complications in high-risk patients. LPS can achieve negative tangential margins in a high percentage of patients with malignant tumors. Although surgical cure is rare in malignant NEPTs, significant long-term palliation can be achieved in a large proportion of patients with an aggressive surgical approach.

Background: Laparoscopic pancreatic surgery should be considered as an advanced laparoscopic procedure and should be performed only in institutions with experience in pancreatic surgery by a team with advanced laparoscopic skills., Aim: This review discusses the current status of the laparoscopic approach for inflammatory pancreatic diseases and for benign-appearing pancreatic tumors., Results: Laparoscopic surgery has been shown to be beneficial in patients with inflammatory tumors located in the body-tail of the pancreas for chronic pancreatitis. Furthermore, patients with pancreatic pseudocysts may be managed with laparoscopic internal drainage (to the stomach, duodenum, or jejunum). Also, laparoscopic or retroperitoneoscopic necrosectomy has been used with success in patients with necrotizing pancreatitis. At present, laparoscopic surgery has proven to be beneficial in patients with cystic pancreatic neoplasms and neuroendocrine pancreatic tumors., Conclusions: The laparoscopic pancreatic approach was recently shown to be feasible and safe. Laparoscopy may contribute to reduced operation time and perioperative blood loss, and reduces surgical stress because of developments in devices, improvements in procedures, and advanced techniques.

The precise role of laparoscopy in the resection of cystic neoplasms of the pancreas (CyNP) remains unknown. In addition, the question of spleen-preserving distal pancreatectomy is controversial. This report evaluates the feasibility and outcome of laparoscopic spleen-preserving distal pancreatectomy (LapSPDP) in 19 patients (17 women and 2 men) with CyNP. A prospective comparison was made between 11 consecutive patients (group I) with splenic vessel preservation (SVP) and 8 patients (group II) without SVP (Warshaw technique). This study used color-Doppler ultrasound (CDUS) as a tool to identify patients at high risk for postoperative splenic complications. The mean tumor size was, in both groups, 5 cm. In group I, with an intent-to-treat basis of SVP, only in 54.5% of patients the spleen was preserved with an intact splenic artery and vein; in the remainder, conversion to the Warshaw technique was required for intraoperative bleeding. Evaluation of intraoperative factors showed that the mean operative time was significantly shorter (165 vs. 222 minutes) and the mean blood loss significantly lower (225 vs. 495 mL) in the group of LapSPDP with the Warshaw technique. No patients required blood transfusion in both groups. The overall conversion rate was 0%. The overall rate of pancreatic fistula was 15% and it was classified as biochemical leak (no clinical symptomatology). Overall splenic complications were observed in 16.6% of patients but occurred only in three patients undergoing LapSPDP with the Warshaw technique; CDUS showed in 2 patients a focal splenic infarct; the third patient had an initial hospital stay of 5 days, was readmitted 2 days later for a massive splenic necrosis, and splenectomy was performed. The overall hospital stay was 5.7 days. At mean follow up of 22 months (range 6-42), there have been no local recurrences.

Laparoscopic pancreatic procedures are still at an evaluation stage with regard to their indications and techniques. Between January 1998 and December 2000, 13 patients with endocrine pancreatic tumours - 11 insulinomas and 2 non-functioning tumours-underwent laparoscopic surgery, laparoscopic ultrasonography being used in all the patients. Enucleation was performed in five patients. The operative time was 2-3 hours. Distal pancreatectomy was performed in six patients with insulinomas, and spleen preservation with intact splenic vessels was feasible in five. Splenectomy was necessary in one patient for technical reasons. Laparoscopic distal pancreatectomy with splenic vessel preservation was performed in two patients with a large (6 and 8 cm) non-functioning tumour. The mean operative time for all the patients undergoing distal pancreatectomy was 4 hours, ranging from 3 to 5 hours. A pancreatic fistula occurred in three patients after tumour enucleation and in two patients after distal pancreatectomy; the mean hospital stay for all patients was 5 days. Enucleation guided by laparoscopic ultrasonography thus allows safe tumour dissection and excision, laparoscopic distal pancreatectomy also being feasible and safe. Splenic salvage with splenic vessel preservation is technically possible. The laparoscopic approach allows a shorter hospital stay and an earlier return to normal activities., (Copyright 2001 Harcourt Publishers Ltd.)

Background: The extent of pancreatic resection and lymphadenectomy, both for Kausch-Whipple pancreatoduodenectomy and for left pancreatectomy, is variable between surgeons, according to their training., Methods: On May 30, 1998, a consensus conference on the surgical treatment of pancreatic cancer took place in Castelfranco Veneto, Italy. A group of 29 European surgeons and pathologists, recognized as international experts, analyzed the surgical and pathological procedures used in European countries to resect pancreatic cancer and examine the specimen., Results: A general agreement was reached on the definitions of standard , 'radical and 'extended radical Kausch-Whipple pancreatoduodenectomy for carcinoma of the head of the pancreas, and standard and 'radical left pancreatectomy for carcinoma of the body and tail of the pancreas. Segmental venous resection, as well as adjacent organ resection, can be performed at the time of standard, radical or extended radical pancreatoduodenectomy or left pancreatectomy if required. The pylorus-preserving procedure is contraindicated only for carcinomas of the anteriorsuperior part of the head of the pancreas. Guidelines for a standardized pathological examination of the resected specimen were produced., Conclusion: Adoption of the recommended terminology will improve outcome comparisons between institutions performing the different procedures. Moreover, standardization of operations, terminology and pathological reporting is essential for prospective randomized trials comparing different operations either alone or within the context of adjuvant therapy studies.

The purpose of this paper is to present the results of our experience in using a conservative pancreatic resection approach in a certain group of patients suffering from chronic pancreatitis. From January 1988 to December 1995, 110 patients underwent surgical therapy for chronic pancreatitis at the Hospital Clinic of the University of Barcelona. In 35 patients with an inflammatory mass at the pancreatic head, pylorus-preserving duodeno-pancreatectomy was performed. Forty male patients with localized focal pancreatitis at the body or tail underwent distal pancreatectomy and drainage of the pancreatic remnant. In 30 patients with pancreatic ducts greater than 7 mm in diameter, side-to-side pancreaticojejunostomy was carried out. Five patients could not be included in any of these three categories because of their particular characteristics. In all cases, resolution of the symptoms was achieved at the mean follow-up of 18 months (range 12 to 21 months). No patient showed a deterioration of glucose homeostasis, and exocrine dysfunction was not observed. Patients with obstructive chronic pancreatitis by inflammatory cystic mass, short strictures or intraductal stones located in the central pancreas or uncinate process may be surgically managed with conservative pancreatic resection or extraction of the stones from the Wirsung duct. The jejunal interposition and pancreaticojejunal anastomosis achieved pain control without any deterioration of the endocrine or exocrine function.