review of literature on clinical pancreatology - The Pancreapedia

procedure is failing to progress laparoscopically, or if cancer surgery principles are likely tobe violated, the surgeon (and the patient) must be willing to abort the laparoscopic approachand complete the operation using standard open technique. During the next few years wecan expect to see more robust outcome data with laparoscopic pancreatectomy. Theexpectation is that more data will come to light demonstrating benefits <strong>of</strong> laparoscopicpancreatic resection as compared with open technique for selected patients. Several groupsare considering randomized trials to look at these endpoints. Although more retrospectiveand prospectively maintained data will certainly be presented, it is less likely that randomizeddata specifically examining the question <strong>of</strong> laparoscopic versus open pancreatectomy forcancer will mature, due to some <strong>of</strong> the limitations discussed above. Additional areas <strong>of</strong>discovery are in staple line reinforcement for left pancreatectomy and suturing technology forpancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery.Improving optics and visualization with flexible endoscopes with provide novel surgical viewspotentially improving the safety <strong>of</strong> laparoscopy. Another area in laparoscopic surgery that isgaining momentum is that <strong>of</strong> Natural Orifice Transluminal Endoscopic Surgery (NOTES).NOTES represents the "holy grail" <strong>of</strong> incisionless surgery. Can we enucleate a small tumor<strong>of</strong>f the pancreatic body by passing an endoscope through the gastric (or colonic) wall, andbring the specimen out via the mouth or anus? Can we use this approach for formal leftpancreatectomies? Pioneers have already developed a porcine model <strong>of</strong> leftpancreatectomy. This technology must clear several hurdles before it is cancer ready;however, technology is moving at a rapid pace [510].Spleen-preserving laparoscopicallyLaparoscopic resection for small lesions <strong>of</strong> the pancreas has recently gained popularity. Itwas reported the initial experience with a new approach to laparoscopic spleen-preservingdistal pancreatectomy so that the maximum amount <strong>of</strong> normal pancreas can be preservedwhile ensuring adequate resection margins and preservation <strong>of</strong> the spleen and splenicvessels. Three patients underwent laparoscopic distal pancreatectomy with spleen andsplenic vessel preservation over a 2-month period. Two patients underwent resection usingthe conventional medial-to-lateral dissection as the lesion was close to the body or proximaltail <strong>of</strong> the pancreas. The third patient had a lesion in the distal tail <strong>of</strong> the pancreas andsurgery was carried out in a lateral-to-medial manner. This new approach minimizedexcessive sacrifice <strong>of</strong> normal pancreatic tissue for such distally located lesions. The splenicartery and vein were preserved in all cases and there was no significant difference in clinicaloutcome, operative time or intraoperative blood loss. It was concluded that although theconventional “medial-to-lateral” approach is recommended for more proximal tumours <strong>of</strong> thepancreas, distal lesions can be safely addressed using the “lateral-to-medial” approach [511].NOTESNatural orifice transluminal endoscopic surgery (NOTES) research has primarily involvedcase series reports <strong>of</strong> low-risk procedures. To compare endoscopic transgastric distalpancreatectomy (ETDP) and laparoscopic distal pancreatectomy a prospective trial in 41swine, laparoscopic pancreatectomy was performed with 3 trocars and stapled transection <strong>of</strong>the pancreas. ETDP was performed via a gastrotomy, with 1 trocar for visualization, by usingendoloop placement, snare transection, and purse-string gastrotomy closure. Swine weresurvived for 8 days. The procedure time for ETDP was significantly greater than for LDP.Pancreatic specimen weight was smilar. Postoperatively, 26 <strong>of</strong> 28 animals thrived. In thelaparoscopic group, 1 death caused by pancreatic leak and renal failure occurred on day 1.In the ETDP group, 1 death caused by pneumothorax occurred intraoperatively. Thenecropsy, CT, and histologic examinations revealed focal resection-margin necrosis in 3 to 7swine in the ETDP group with no proximal necrosis or pancreatitis. The groups wereequivalent clinically, by survival, and by serum and peritoneal fluid analysis. The gastrotomy