Fernández-Cruz Laureano, Cosa Rebeca, Blanco Laia, Levi Sammy, López-Boado Miguel-Angel, Navarro Salvador
Surgical Department, ICMD Hospital Clínic de Barcelona, Villarroel, 170, 08036 Barcelona, Spain.
J Gastrointest Surg. 2007 Dec;11(12):1607-21; discussion 1621-2. doi: 10.1007/s11605-007-0266-0. Epub 2007 Sep 25.
Laparoscopic pancreatic surgery (LPS) has seen significant development but much of the knowledge refers to small and benign pancreatic tumors. This study aims to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with benign, premalignant, and overt malignant lesions of the pancreas. This study, currently, is the largest single center experience worldwide. One hundred twenty-three consecutive patients underwent laparoscopic pancreatic surgery from April 1998 to April 2007, 20 patients with cysts or pseudocysts for acute and chronic pancreatitis, laparoscopic pancreatic drainage was performed, and were excluded from the analysis. The 103 patients were divided based on preoperative diagnosis: group I, inflammatory tumors for chronic pancreatitis (eight patients); group II, cystic pancreatic neoplasms (29 patients); group III, intraductal papillary mucinous neoplasms (10 patients); group IV, neuroendocrine pancreatic tumors (NETs) (43 patients); and group V ductal adenocarcinoma (13 patients). The median tumor size was 5.3 cm. Pathologic data include R(0) or R(1) resection (transection margins on the specimen were inked). Perioperative data, postoperative complications, and resection modalities were compared using statistical analysis. Long-term outcomes were analysed by tumor recurrence and patient survival. The overall conversion rate was 7%. Laparoscopic distal pancreatic resection was performed in 82 patients (79.6%). Laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP) was performed in 52 patients (63.7%), but with splenic vessels preservation in 22% and without splenic vessels preservation in 41.5%. Laparoscopic en-bloc splenopancreatectomy (Lap SxDP) was performed in 30 patients (36.6%) and laparoscopic enucleation (Lap En) in 20 patients (19.4%). There was no mortality. The overall complication rate was 25.2, 16.7, and 40% after Lap SPDP, Lap SxDP, and Lap En, respectively. The overall morbidity rate was significantly higher (p>0.05) in the group of Lap SPDP without splenic vessels preservation comparing with Lap SPDP with splenic vessels preservation because of the occurrence of splenic complications (20.6%). The overall pancreatic fistulas was 7.7, 10, and 35% after Lap SPDP, Lap SxDP, and Lap En, respectively; the severity of fistula was significantly higher in the Lap En group (p>0.05). The mean hospital stay was within 1 week in all groups, except in the group of ductal adenocarcinoma, which is 8 days. In this series, 27 patients (26.2%) had malignant disease. R(0) resection was achieved in 90% of ductal adenocarcinoma and 100% for other malignant tumors. The median survival for ductal adenocarcinoma patients was 14 months. This series demonstrates that LPS is feasible and safe in benign-appearing and malignant lesions of the pancreas.
腹腔镜胰腺手术（LPS）已取得显著进展，但大部分知识都涉及小型良性胰腺肿瘤。本研究旨在评估腹腔镜手术方法在胰腺良性、癌前和明显恶性病变患者中的可行性、安全性及长期疗效。本研究是目前全球最大的单中心经验总结。1998年4月至2007年4月，连续123例患者接受了腹腔镜胰腺手术，其中20例因急性和慢性胰腺炎的囊肿或假性囊肿接受了腹腔镜胰腺引流术，这些患者被排除在分析之外。103例患者根据术前诊断进行分组：第一组，慢性胰腺炎的炎性肿瘤（8例）；第二组，胰腺囊性肿瘤（29例）；第三组，导管内乳头状黏液性肿瘤（10例）；第四组，胰腺神经内分泌肿瘤（NETs）（43例）；第五组，导管腺癌（13例）。肿瘤中位大小为5.3厘米。病理数据包括R(0)或R(1)切除（标本的横断边缘用墨水标记）。采用统计分析比较围手术期数据、术后并发症及切除方式。通过肿瘤复发和患者生存情况分析长期疗效。总体中转率为7%。82例患者（79.6%）接受了腹腔镜远端胰腺切除术。52例患者（63.7%）接受了腹腔镜保脾远端胰腺切除术（Lap SPDP），其中22%保留了脾血管，41.5%未保留脾血管。30例患者（36.6%）接受了腹腔镜整块脾胰切除术（Lap SxDP），20例患者（19.4%）接受了腹腔镜摘除术（Lap En）。无死亡病例。Lap SPDP、Lap SxDP和Lap En术后总体并发症发生率分别为25.2%、16.7%和40%。未保留脾血管的Lap SPDP组总体发病率显著高于保留脾血管的Lap SPDP组（p>0.05），原因是出现了脾脏并发症（20.6%）。Lap SPDP、Lap SxDP和Lap En术后总体胰瘘发生率分别为7.7%、10%和35%；Lap En组瘘的严重程度显著更高（p>0.05）。除导管腺癌组平均住院时间为8天外，所有组的平均住院时间均在1周内。在本系列中，27例患者（26.2%）患有恶性疾病。导管腺癌90%实现了R(0)切除，其他恶性肿瘤为100%。导管腺癌患者的中位生存期为14个月。本系列研究表明，LPS在胰腺良性外观和恶性病变中是可行且安全的。
