Although there are still controversies over the efficiency and safety of minimally invasive radical surgery for pancreatic ductal adenocarcinoma (PDAC), most available studies have suggested a promising application of minimally invasive radical surgery. This consensus, referring to Chinese expert opinions and worldwide researches, aimed to discuss the related issues on minimally invasive radical surgery for PDAC to ensure the perioperative and oncological outcomes. Quality of evidence and strength of recommendations were evaluated based on the GRADE approach. The 15 recommendations covered 5 topics: oncological outcomes and patient safety of laparoscopic and robotic pancreatoduodenectomy, left-side pancreatectomy for PDAC, learning curve, safety of neoadjuvant therapy, and vascular resection in minimally invasive radical surgery for PDAC. This consensus gives reference and guidance to surgeons on the use of minimally invasive radical surgery for PDAC. Although this consensus is not sufficient to answer all the questions about minimally invasive radical surgery for PDAC, it represents the current consensus on the application of the techniques in the treatment of PDAC on the Chinese mainland.
Humans ; Carcinoma, Pancreatic Ductal/surgery* ; Consensus ; Laparoscopy/methods* ; Minimally Invasive Surgical Procedures/methods* ; Pancreatectomy/methods* ; Pancreatic Neoplasms/pathology* ; Treatment Outcome ; China

Objective: To explore the development of the pancreatic surgeon technique in a high-volume center. Methods: A total of 284 cases receiving pancreatic surgery by a single surgeon from June 2015 to December 2020 were retrospectively included in this study. The clinical characteristics and perioperative medical history were extracted from the medical record system of Zhongshan Hospital,Fudan University. Among these patients,there were 140 males and 144 females with an age (M (IQR)) of 61.0 (16.8) years(range: 15 to 85 years). The "back-to-back" pancreatic- jejunal anastomosis procedure was used to anastomose the end of the pancreas stump and the jejunal wall. Thirty days after discharge,the patients were followed by outpatient follow-up or telephone interviews. The difference between categorical variables was analyzed by the Chi-square test or the CMH chi-square test. The statistical differences for the quantitative data were analyzed using one-way analysis of variance or Kruskal-Wallis H test and further analyzed using the LSD test or the Nemenyi test,respectively. Results: Intraoperative blood loss in pancreaticoduodenectomy between 2015 and 2020 were 300,100(100),100(100),100(0),100(200) and 150 (200) ml,respectively. Intraoperative blood loss in distal pancreatectomy was 250 (375),100 (50),50 (65), 50 (80),50 (50),and 50 (100) ml,respectively. Intraoperative blood loss did not show statistical differences in the same operative procedure between each year. The operative time for pancreaticoduodenectomy was respectively 4.5,5.0(2.0),5.5(0.8),5.0(1.3),5.0(3.3) and 5.0(1.0) hours in each year from 2015 to 2020,no statistical differences were found between each group. The operating time of the distal pancreatectomy was 3.8 (0.9),3.0 (1.5),3.0 (1.8),2.0 (1.1),2.0 (1.5) and 3.0(2.0) hours in each year,the operating time was obviously shorter in 2018 compared to 2015 (P=0.026) and 2020 (P=0.041). The median hospital stay in 2020 for distal pancreatectomy was 3 days shorter than that in 2019. The overall incidence of postoperative pancreatic fistula gradually decreased,with a incident rate of 50.0%,36.8%,31.0%,25.9%,21.1% and 14.8% in each year. During this period,in a total of 3,6,4,2,0 and 20 cases received laparoscopic operations in each year. The incidence of clinically relevant pancreatic fistula (grade B and C) gradually decreased,the incident rates were 0,4.8%,7.1%,3.4%,4.3% and 1.4%,respectively. Two cases had postoperative abdominal bleeding and received unscheduled reoperation. The overall rate of unscheduled reoperation was 0.7%. A patient died within 30 days after the operation and the overall perioperative mortality was 0.4%. Conclusion: The surgical training of a high-volume center can ensure a high starting point in the initial stage and steady progress of pancreatic surgeons,to ensure the safety of pancreatic surgery.
Male ; Female ; Humans ; Pancreatic Fistula/surgery* ; Retrospective Studies ; Blood Loss, Surgical ; Pancreatectomy/methods* ; Pancreaticoduodenectomy ; Postoperative Complications ; Surgeons ; Postoperative Hemorrhage ; Pancreatic Neoplasms/surgery*

Objective: To compare the outcomes of modified Appleby procedure and sub-adventitial divestment technique for locally advanced or borderline resectable pancreatic body cancer. Methods: A total of consecutive 58 patients(33 males and 25 females) who were diagnosed as locally advanced or borderline resectable pancreatic body cancer and underwent distal pancreatectomy at Pancreas Center, First Affiliated Hospital of Nanjing Medical University between September 2013 and May 2019 were retrospectively reviewed. The age(M(IQR)) was 62(9)years(range: 43 to 79 years). Thirty-one patients underwent distal pancreatectomy with celiac axis resection (DP-CAR) and 27 patients underwent distal pancreatectomy with sub-adventitial divestment technique(SDT). Perioperative parameters and follow-up data of these patients were analyzed. Quantitative data were compared with Wilcoxon test while categorical variables were compared with χ² test or Fisher's exact test. Survival results were estimated by the Kaplan-Meier survival method with a Log-rank test. Results: There were no differences in age,gender,body mass index,abdominal symptoms,comorbidity or preoperative serum CA19-9 between two groups(all P>0.05). Obvious preoperative weight loss was more common in the group of SDT(48.1%(13/27) vs. 19.4%(6/31),χ²=5.431,P=0.020). Longer operative time(310(123) minutes vs. 254(137)minutes, Z=2.277,P=0.023),higher rate of combined organ resection(41.9%(13/31) vs. 14.8%(4/27),χ²=5.123,P=0.041) and longer postoperative hospital stay(15(10) days vs. 11(5)days,Z=2.292,P=0.022) were observed in the group of DP-CAR. Moreover,rate of overall morbidities was also higher (71.0%(22/31) vs. 29.6%(8/27),χ²=9.876,P=0.003),implicated by clinically relevant postoperative pancreatic fistula(61.3%(19/31) vs. 29.6%(8/27),χ²=5.814,P=0.020) in the DP-CAR group. Tumor size of the DP-CAR group was bigger(4.9(1.5)cm vs. 4.0(1.2)cm,Z=2.343,P=0.019) but no difference was seen between the DP-CAR group and SDT group in R0+R1(<1 mm) resection rate (84.0%(21/25) vs. 90.0%(18/20),P=0.678) and LNR(12.0(23.0)% vs. 9.0(18.0)%,Z=1.238,P=0.216),as well as median disease free survival(11.7 months vs. 11.4 months,Z=0.019,P=0.892) and median overall survival(16.3 months vs. 13.7 months,Z=0.172,P=0.679). Conclusions: Both DP-CAR and distal pancreatectomy with SDT are relatively safe and feasible for locally advanced or borderline resectable pancreatic body cancer. Compared with arterial resection,SDT may contribute to lower rates of postoperative complications and shorter duration of hospitalization,but no significant benefit is seen in long-term survival.
Celiac Artery/surgery* ; Female ; Humans ; Male ; Pancreatectomy/methods* ; Pancreatic Neoplasms/pathology* ; Postoperative Complications ; Retrospective Studies

PURPOSE: Central pancreatectomy (CP) may be indicated for the treatment of benign or low-grade malignant tumor in the neck and proximal body of the pancreas. Pancreatic fistula is one of the most common complications after CP. In this study, we suggested an inverted mattress pancreaticojejunostomy (IM-PJ) technique to decrease the risk of pancreatic fistula. METHODS: Between 2010 and 2015, CP was performed with IM-PJ for 10 consecutive patients with a benign or low-grade malignant tumor in the neck and proximal body of the pancreas. All clinical and pathological data were analyzed retrospectively. RESULTS: Median age was 56.4 years (range, 17–75 years). Median surgery duration was 286 minutes (range, 205–410 minutes). In all cases, the distal stump was reconstructed using the IM-PJ method. Median duration of hospital stay was 23.8 days (range, 9–53 days). No patient mortality occurred. Pancreatic fistula developed in 9 cases (90%); however, all fistulas were grade A and resolved without surgical or radiological intervention. Nine patients remain well with no recurrence or new endocrine or exocrine dysfunction. CONCLUSION: Our results demonstrate that the outcomes of CP with IM-PJ are reasonable for prevention of pancreatic fistula following CP.
Fistula ; Humans ; Length of Stay ; Methods ; Mortality ; Neck ; Pancreas ; Pancreatectomy* ; Pancreatic Fistula* ; Pancreaticojejunostomy* ; Recurrence ; Retrospective Studies

Objective: To evaluate the feasibility and safety of applying enhanced recovery after surgery (ERAS) protocol in patients undergoing laparoscopic distal pancreatectomy. Methods: Data of 36 patients undergoing laparoscopic distal pancreatectomy from May 2016 to May 2017 in the First Affiliated Hospital, Zhejiang University School of Medicine were reviewed. The patients were divided into ERAS group (n=12) and control group (n=24). The patients in ERAS group received a series of enhanced recovery procedures, including multimodal analgesia, early off-bed activity and early oral food-taking, etc. Operation time, intraoperative blood loss, time to first flatus, postoperative complications, and length of postoperative hospital stay were evaluated. Results: There were no statistically significant differences in operation time and intraoperative blood loss between ERAS group and control group (all P0.05). The time to first flatus and length of postoperative hospital stay were significantly shortened in ERAS group (all P<0.05). The ERAS group had lower incidence of postoperative complications (41.7% vs. 66.7%), and the complications in ERAS group tended to be milder, but the differences failed to show statistical significance (all P0.05). Conclusion: The ERAS protocol for laparoscopic distal pancreatectomy can significantly promote gastrointestinal function recovery and shorten postoperative hospital stay, and may reduce the incidence of postoperative complications.
Case-Control Studies ; Humans ; Laparoscopy ; standards ; Length of Stay ; Pancreatectomy ; instrumentation ; methods ; Postoperative Complications ; prevention & control ; Postoperative Period ; Retrospective Studies

OBJECTIVETo investigate the value and safety of the surgery with vascular resection and reconstruction during pancreatectomy for pancreatic cancer.

METHODSThe clinical data of 206 patients with pancreatic cancer who underwent radical resection were retrospectively analyzed from January 2009 to March 2014 in Lihuili Hospital, Medical center of Ningbo.All cases were divided into non-vascular resection group(132 cases), the combined vein resection group(66 cases) and the combined arterial resection group(8 cases). The peri-operation data, the incidence of postoperative complications and the survival were compared in pairs among three groups.All patients were followed up till September 2014.

RESULTSThere were no statistical differences for the preoperative data among three groups.The operation time and the blood loss (M(QR)) were (347±96)minutes and (500(400)) ml in non-vascular resection group, (425±91)minutes and (800(500))ml in combined vein resection group, (508±120)minutes and (1 750(2 075))ml in combined arterial resection group, with significant differences among three groups(all P<0.01). The incidence of postoperative complication was 16.7%(22/132) in non-vascular resection group, 28.8%(19/66) in combined vein resection group, and 6 cases in combined arterial resection group, respectively.There were significant differences between non-vascular resection group and combined vein resection group(P<0.05), non-vascular resection group and combined arterial resection group(P<0.05), as well as between combined vein resection group and combined arterial resection group(P<0.05). The median survival time was 15 months for non-vascular resection group, 15 months for combined vein resection group, and 12 months for combined arterial resection group.No significant difference was found among three groups(all P>0.05). The postoperative mortality was nil for all of groups.

CONCLUSIONSCompared with non-vascular resection, combined vein resection can be performed safely with a similar prognosis. The surgery of combined arterial resection could only be justified when R0 resection for pancreatic cancer could be achieved for highly selected patients.

Arteries ; surgery ; Humans ; Pancreatectomy ; methods ; Pancreatic Neoplasms ; surgery ; Postoperative Complications ; Prognosis ; Retrospective Studies ; Veins ; surgery

INTRODUCTIONThe use of laparoscopic distal pancreatectomy (LDP) has increased worldwide due to the reported advantages associated with this minimally invasive procedure. However, widespread adoption is hindered by its technical complexity. Robotic distal pancreatectomy (RDP) was introduced to overcome this limitation, but worldwide experience with RDP is still lacking. There is presently evidence that RDP is associated with decreased conversion rate and increased splenic preservation as compared to LDP.

METHODSWe conducted a prospective study on our initial experience with robotic spleen-saving, vessel-preserving distal pancreatectomy (SSVP-DP) between July 2013 and April 2014.

RESULTSThree consecutive patients underwent attempted robotic SSVP-DP. The indications were a 2.1-cm indeterminate cystic neoplasm, 4.5-cm solid pseudopapillary neoplasm and 1.2-cm pancreatic neuroendocrine tumour. For all three patients, the procedure was completed without conversion, and the spleen, with its main vessels, was successfully conserved. The median total operation time, blood loss and postoperative stay were 350 (range 300-540) minutes, 200 (range 50-300) mL and 7 (range 6-14) days, respectively. Two patients had minor Clavien-Dindo Grade I complications (one Grade A pancreatic fistula and one postoperative ileus). One patient had a Clavien-Dindo Grade IIIa complication (Grade B pancreatic fistula requiring percutaneous drainage). All patients were well at the time of reporting after at least six months of follow-up.

CONCLUSIONOur preliminary experience with robotic SSVP-DP confirmed the feasibility of the procedure.

Female ; Follow-Up Studies ; Humans ; Laparoscopy ; methods ; Male ; Middle Aged ; Organ Sparing Treatments ; Pancreatectomy ; methods ; Pancreatic Neoplasms ; surgery ; Patient Positioning ; Prospective Studies ; Robotic Surgical Procedures ; Singapore ; Spleen ; surgery ; Young Adult

OBJECTIVETo explore the learning curve for middle pancreatectomy by comparing the outcomes of middle pancreatectomy operated by a single treatment group at different stages.

METHODSA total of 48 patients received middle pancreatectomy by single treatment group between January 2006 and April 2014 at our hospital. These 48 cases were divided into 10 stages (5 cases in each) according to the operation sequence. The operation time, blood loss, surgical complications, rate of negative margin and postoperative hospital stay were analyzed retrospectively.

RESULTSThere was no significant difference among the 10 stages in respect to surgical complications, rate of negative margin and postoperative hospital stay (P>0.05). The median operation time and blood loss in the first stage was 375 min and 530 ml, respectively. The median operation time and blood loss in the second stage was 280 min and 330 ml, respectively. There were significant differences between these two stages and the other later stages in median operation time and blood loss (P<0.01). However, there was no significant difference among the stages 3 to 10 in the median operation time and blood loss (P>0.05 for all).

CONCLUSIONAfter 10-15 cases of middle pancreatectomy, a surgeon can be skilled and experienced in this surgical procedure with few surgical complications.

Humans ; Learning Curve ; Length of Stay ; Operative Time ; Pancreatectomy ; methods ; Retrospective Studies

OBJECTIVETo compare the safety and effectiveness of DPPHR with PPPD/PD for treating chronic pancreatitis with an inflammatory mass in the head of pancreas.

METHODSThe relative data bases such as Medline, EMBase, Biosis, COCHRANE Library, Science Citation Index, SinoMed, Chinese Journal Full-text Database, Wangfang, CNKI were searched systematically, researchers selected randomized controlled trials (RCT) and prospective clinical controlled trials (CCT) . The assessment of the bias risk of the included trials was according to the assessing tools suggested by Cochrane Handbook 5.1. The Review Manage 5.2 was used to perform the statistical analysis.

RESULTSIn total, 5 RCTs and 2 CCTs were included, 381 patients involved. Comparing with PPPD/PD procedure, DPPHR has no significant difference in terms of the mortality of perioperative period (RD = 0.01, P = 0.51), the incidence of bleeding (RD = -0.01, P = 0.72), pancreatic fistula(RD = -0.01, P = 0.59) and delayed gastric emptying (RD = -0.15, P = 0.10), the ration of complete pain relief after operation (RR = 1.06, P = 0.32) and the score of global quality of life (WMD = 10.31, P = 0.19).While DPPHR had significant superiorities in terms of the total morbidity of perioperative period (RR = 0.60, P = 0.008), the duration of the operations(WMD = -71.60, P = 0.03), the postoperative hospitalization duration(WMD = -3.95, P < 0.01), weight gain(WMD = 3.68, P < 0.01), occupational rehabilitation after the operations (RR = 1.38, P = 0.008).

CONCLUSIONSIn terms of reducing the morbidity of perioperative period, shortening the duration of the operations and the postoperative hospitalization duration, weight gain, occupational rehabilitation after the operations, the DPPHR is more favorable for improving patients' life qualities comparing with PPPD/PD.

Duodenum ; surgery ; Humans ; Pancreas ; surgery ; Pancreatectomy ; methods ; Pancreaticoduodenectomy ; methods ; Pancreatitis, Chronic ; surgery ; Prospective Studies ; Quality of Life

OBJECTIVETo raise the awareness of adenosquamous carcinoma of pancreas and discuss the treatment of it.

METHODSClinical data of 80 cases of pancreas adenosquamous carcinoma patients in the Department of Pancreas Surgery of Changhai Hospital of Second Military Medical University from December 2003 to October 2011 were analyzed. The diagnose and treatment methods were discussed. There were 61 male cases and 19 female cases who aged from 28 to 81 years, with an average age of 60 years. The primary symptoms included 46 cases (57.5%) of abdominal malaise, 6 cases (7.5%) of low back pain, 4 cases (5.0%) of abdominal swelling pain with low back pain, 15 cases (18.8%) of abdominal swelling pain with jaundice, 5 cases (6.3%) of painless jaundice, 3 cases (3.8%) of significantly decreased body-weight and 1 case (1.3%) of no symptom. All the patients had been identified as pancreas tumor suffers by ultrasound, enhanced CT scan or MRI. Totally there were 43 cases of head/unciform process tumors, 15 cases of pancreas body tumors and 22 pancreas tail cases.Health situation of all cases were follow-up observed in the outpatient department or telephoned every 3 months till 24 months after the surgery.

RESULTSAmong the 80 patients, 19 patients underwent pancreaticoduodenectomy (PD) , 19 patients received pylorus-preserving PD, with 4 cases of palliative resection and 1 case of total pancreatectomy. The volume of bleeding during the surgery varied from 50 to 3 500 ml with a blood transfusion volume varied from 0 to 4 000 ml. Consumed time for PD procedures was 90 to 260 min with 60 to 150 min for body and (or) tail resection with or without lienectomy. The mean diameter of tumor was (4.9 ± 2.2) cm. Pathological tests showed 35 cases of positive lymph nodes, adjacent organ invasion happened in 35 patients, however, nerve invasion were found in 68 cases.Eighteen cases occurred postoperative complications, including bleeding, pancreatic fistula, gastric emptying, incision fat liquefaction and infection, pleural effusion, ascites and nervous diarrhea. There were only 48 effective follow-up patients, with a loss ratio of follow-up by 40.0%, reasons for the loss includes change of contact information, refuse or unable to provide useful information by the relatives of the patients.Sixteen patients received chemotherapy, and 8 patients received radiotherapy after operation. All patients were dead in the effective follow-ups. The postoperative median survival time was 6 months (0.1 to 23.0 months).

CONCLUSIONSAdenosquamous carcinoma of pancreas is a rare kind of malignant tumor, nerve invasion can be found in almost all the cases. Patients with adenosquamous carcinoma of pancreas have an unfavorable prognosis. The principle treatments are surgery, radiotherapy and chemotherapy.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Carcinoma, Adenosquamous ; mortality ; pathology ; surgery ; Female ; Humans ; Male ; Middle Aged ; Pancreas ; pathology ; Pancreatectomy ; methods ; Pancreatic Neoplasms ; mortality ; pathology ; surgery ; Pancreaticoduodenectomy ; methods ; Postoperative Complications ; mortality ; Prognosis ; Young Adult