laparoscopic pancreatic surgery

LAPAROSCOPIC PANCREATIC

SURGERYGeorge Ferzli MD, FACS

? What is the current role of

laparoscopic surgery with regard to pancreatic disease?

Role of laparoscopyDIAGNOSTIC

Tumor staging

THERAPEUTIC

Curative- tumors- pseudocyst- pancreatic necrosis

- trauma

Palliative

I- Diagnostic

“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

• Prospective study of 88 consecutive patients

• Pancreatic and periampullary adenocarcinoma

• Preoperative evaluation– CT scan with contrast 88 pts– MRI 20 pts– Laparoscopy 47 pts– Angiography 85 pts

Preoperative Staging and Assessment of Resectability of Pancreatic Cancer

Warshaw,A et al: Arch Surg 1990; 125:230-233

Results

• Overall resectability 33/88 (38%)

• Laparoscopy found metastatic disease when present in 22/23 patients (96%)

• Laparoscopy found no metastatic disease in 24/24 patients (100%)

Warshaw,A et al: Arch Surg 1990; 125:230-233

Conclusion

• Laparoscopy is particularly sensitive for detecting small metastases (96%)

• This approach to pancreatic cancer allows the elimination of some operations and tailors others to individual circumstances

Warshaw,A et al: Arch Surg 1990; 125:230-233

The Value of Minimal Access Surgery in the Staging of Patients with

Potentially Resectable Peripancreatic Malignancies

• 115 patients- radiologically resectable

• Extensive laparoscopy performed

– assessment of the peritoneal cavity, liver, lesser sac, porta hepatis, duodenum, transverse mesocolon, and celiac and portal vessels

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

Unresectability

• Metastases– hepatic, serosal, peritoneal

• Extrapancreatic extension– mesocolic involvement

• Nodal involvement– celiac or portal

• Vascular invasion– celiac axis or hepatic artery– portal vein, SMV, SMA

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

• No intraoperative or postoperative complications related to laparoscopy

• 67 considered resectable 61 resected

• Laparoscopy failed to identify hepatic metastases in 5 patients and portal venous encasement in 1 patient

Results

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

• Positive predictive index of 100%

• Negative predictive index of 91%

• Accuracy of 94%

Results

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

Extended laparoscopy is accurate and safe and makes exploration unnecessary in many patients with potentially resectable peripancreatic

malignancy

Conclusion

Conlon,K et al;Ann Surg 1996 Vol223,No2, 134-140

Experience with staging laparoscopy in pancreatic malignancy

Gastrointest Endo 1999; 49(4):498-503

• 109 patients

• CT scan revealed metastases in 10 patients

• Laparoscopy diagnosed metastases in 29 more patients

• At laparotomy, 6 more patients were identified as having metastatic disease

Results

• Negative predictive value was 94%

• Positive predictive value was 88%

Conclusion

• 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.

Laparoscopic Ultrasound in the Staging of Pancreatic Cancer

• Prospective evaluation of 90 patients

• All patients had preoperative CT abdomen/pelvis and either ERCP or transabdominal sonography

• All patients had laparoscopy and laparoscopic ultrasound

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

Tumor location

Pancreatic head 64 (72%)

Pancreatic body 19 (21%)

Pancreatic tail 3 (3%)

Ampulla 4 (4%)

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

CT LAP LAP SONO

ACTUAL

UNRESECTABLE 17

(19%)

41

(46%)

49

(54%)

50

(56%)

EQUIVOCAL 8

(9%)

13

(14%)

___ ___

Results

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

LAPAROSCOPIC ULTRASOUND

• SENSITIVITY 100%

• SPECIFICITY 98%

• ACCURACY 98%

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

Conclusion

The addition of laparoscopic ultrasound offers improved assessment and preoperative staging of pancreatic cancer.

Minnard, E. Conlon, K et al, Ann Surg, 1998, 228(2)

Summary

Staging laparoscopy should be performed for all cases of pancreatic cancer prior to attempted resection

The addition of laparoscopic ultrasound improves assessment and preoperative staging of pancreatic cancer

II- Therapeutic Laparoscopy

1- LAPAROSCOPIC PANCREATICODUODENECTOMY

• Gagner and Pomp – 1996• Strasberg, Drebin, and Soper – 1997• Cuschieri – 1998

CONCLUSION: THE MAGNITUDE OF THE RECONSTRUCTION

MAY OUTWEIGH THE BENEFIT OF THE MINIMALLY INVASIVE APPROACH

2- MISCELLANEOUS PANCREATIC NEOPLASMS

STUDY DESCRIPTIONSPITZ, et al

Surg Lap Endo Vol 10, 2000

Ultrasound Guided Laparoscopic Resection Of Pancreatic Islet Cell

Tumors

PETERSON, et al

J Am Coll Surg 193(2),2001

Laparoscopic Pancreatic Resection: Single Institution Experience of

19 Patients

World Journal of Surgery Vol. 26, 2002

Videolaparoscopic Resection of Insulinomas

3- Management of pancreatic pseudocyst and necrotizing

pancreatitis

Laparoscopic Cholecystectomy and Acute Laparoscopic Cholecystectomy and Acute Biliary PancreatitisBiliary PancreatitisE Tang , NJ Soper , JJT Tate, W Uhl

• 271 biliary pancreatitis, 22 % Ranson 271 biliary pancreatitis, 22 % Ranson ≥≥ 3 3• Laparoscopic cholecystectomy 86 %Laparoscopic cholecystectomy 86 %

• Early operation and Ranson Early operation and Ranson ≥≥ 3 were associated 3 were associated with:with:

- more technical difficulties- more technical difficulties

- more conversions- more conversions

- more CBD stones- more CBD stones

ConclusionsConclusions

1. Past pancreatitis is a poor indicator of CBDS. IOC is IOC is indicated regardless of the risk of CBDS.indicated regardless of the risk of CBDS.

2.2. Prognostic systems can discriminate patients with non Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).severe ABP (Negative Predictive Value).

3.3. Timing of open or laparoscopic biliary Timing of open or laparoscopic biliary surgery depends on AP severitysurgery depends on AP severity

Urgent ERC/ES in Benign Acute Biliary Urgent ERC/ES in Benign Acute Biliary PancreatitisPancreatitis

Neoptolemos Neoptolemos Fan Fan

ERC ERC ControlsControls ERCERC ControlsControls

n (%)n (%) n (%)n (%) n (%)n (%)n (%) n (%)

N patientsN patients 2828 2929 3434 3535

ComplicationsComplications

- local- local 3 (11)3 (11) 4 (14)4 (14) 7 (21)7 (21) 1 (3) 1 (3)

- general - general 1 (4)1 (4) 00 3 (9)3 (9) 1 1 (3)(3)

DeathsDeaths 00 00 00 00

Neoptolemos Neoptolemos Fan Fan

ERC ERC ControlsControls ERCERC ControlsControls

n (%)n (%) n (%)n (%) n (%)n (%)n (%) n (%)

N patientsN patients 2828 2929 3434 3535

ComplicationsComplications

- local- local 3 (11)3 (11) 4 (14)4 (14) 7 (21)7 (21) 1 (3) 1 (3)

- general - general 1 (4)1 (4) 00 3 (9)3 (9) 1 1 (3)(3)

DeathsDeaths 00 00 00 00

ConclusionsConclusions

1. Past pancreatitis is a poor indicator of CBDS. IOC is IOC is indicated regardless of the risk of CBDS.indicated regardless of the risk of CBDS.

2. Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).

3. Timing of open or laparoscopic biliary surgery depends on AP severity.

4.4. Endoscopic sphincterotomy is NOT Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary indicated in Benign Acute Biliary PancreatitisPancreatitis

Surgery vs Endoscopic Sphincterotomy in Surgery vs Endoscopic Sphincterotomy in Severe CholangitisSevere Cholangitis

EndoscopyEndoscopySurgerySurgery p p

Leese (non randomized)Leese (non randomized)

Mortality (%)Mortality (%) 4.74.7 21.421.4

Lai (randomized) N patientsN patients 4141 4141

N (%) with ComplicationsN (%) with Complications 14 (34)14 (34) 27 (66)27 (66) < < 0.050.05

DeathsDeaths 4 (10)4 (10) 13 (32)13 (32) < < 0.030.03

EndoscopyEndoscopySurgerySurgery p p

Leese (non randomized)Leese (non randomized)

Mortality (%)Mortality (%) 4.74.7 21.421.4

Lai (randomized) N patientsN patients 4141 4141

N (%) with ComplicationsN (%) with Complications 14 (34)14 (34) 27 (66)27 (66) < < 0.050.05

DeathsDeaths 4 (10)4 (10) 13 (32)13 (32) < < 0.030.03

ConclusionsConclusions

1. Past pancreatitis is a poor indicator of CBDS. IOC is IOC is indicated regardless of the risk of CBDS.indicated regardless of the risk of CBDS.

2.2. Prognostic systems can discriminate patients with non Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).severe ABP (Negative Predictive Value).

3. Timing of open or laparoscopic biliary surgery depends on AP severity.

4. Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis.

5.5. Endoscopic sphincterotomy is indicated in Endoscopic sphincterotomy is indicated in Severe Severe Cholangitis Cholangitis associatedassociated with Severe with Severe ABPABP

Pre- Pre- vsvs Postoperative ERCP in mild Postoperative ERCP in mild ABPABPChang L,et al. Ann Surg 2000.Chang L,et al. Ann Surg 2000.

Pre- Pre- vsvs Postoperative ERCP in mild Postoperative ERCP in mild ABPABPChang L,et al. Ann Surg 2000.Chang L,et al. Ann Surg 2000.

ERC + (LC+IOC)ERC + (LC+IOC) (LC+IOC) + (LC+IOC) + ESES

N of patients 30 29

ERCERC 30 30 7 7 CBD stones / ES 12 (40%) / 11 8 (28%) / 7Overall stay (days) * 11.7 ± 6.1 9 ± 3.2Costs ($) * 10,210 ± 3839 8,586 ±

3520* p < 0.05

ERC + (LC+IOC)ERC + (LC+IOC) (LC+IOC) + (LC+IOC) + ESES

N of patients 30 29

ERCERC 30 30 7 7 CBD stones / ES 12 (40%) / 11 8 (28%) / 7Overall stay (days) * 11.7 ± 6.1 9 ± 3.2Costs ($) * 10,210 ± 3839 8,586 ±

3520* p < 0.05Savings in terms of complications and costs can be Savings in terms of complications and costs can be

expected if preoperative ERCPs are replaced by IOC expected if preoperative ERCPs are replaced by IOC ((Erickson 1995, Sees 1997, Erickson 1995, Sees 1997, Barwood 2002)Barwood 2002)

Savings in terms of complications and costs can be Savings in terms of complications and costs can be expected if preoperative ERCPs are replaced by IOC expected if preoperative ERCPs are replaced by IOC ((Erickson 1995, Sees 1997, Erickson 1995, Sees 1997, Barwood 2002)Barwood 2002)

ConclusionsConclusions

1. Past pancreatitis is a poor indicator of CBDS. IOC is IOC is indicated regardless of the risk of CBDS.indicated regardless of the risk of CBDS.

2.2. Prognostic systems can discriminate patients with non Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).severe ABP (Negative Predictive Value).

3. Timing of open or laparoscopic biliary surgery depends on AP severity.

4. Endoscopic sphincterotomy is NOT indicated in Benign Acute Biliary Pancreatitis .

5. Endoscopic sphincterotomy is indicated in case of Severe Cholangitis associated with Severe ABP.

6.6. CBD exploration is more efficient than CBD exploration is more efficient than ERC/ES. Performing ERC ERC/ES. Performing ERC afterafter LC+IOC LC+IOC rather than before LC minimizes costs and rather than before LC minimizes costs and morbidity morbidity 

Percutaneous and Laparoscopic Percutaneous and Laparoscopic Management of Infected Pancreatic Management of Infected Pancreatic Necrosis. Necrosis.

Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001

Number of patientsNumber of patients 3838

ComplicationsComplications Hemorrhage 4Digestive Fistula 4

(10%%) Pancreatic Fistula 4 (11%%) Persisting Sepsis 5

ReoperationsReoperations Laparoscopic 28Arterial embolization 2Laparotomy 9

(24%%)

MortalityMortality 4 (11%)4 (11%)

Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001Gambiez 1998 - Carter 2000 - Alverdy 2000 - Horvath 2001

Number of patientsNumber of patients 3838

ComplicationsComplications Hemorrhage 4Digestive Fistula 4

(10%%) Pancreatic Fistula 4 (11%%) Persisting Sepsis 5

ReoperationsReoperations Laparoscopic 28Arterial embolization 2Laparotomy 9

(24%%)

MortalityMortality 4 (11%)4 (11%)

Local Complications (%) Associated with Local Complications (%) Associated with Surgical Management of Infected Pancreatic Surgical Management of Infected Pancreatic NecrosisNecrosis

Necrosectomy Retroper.

LaparoscopyLaparoscopy drainage lavagelavage laparotomy Approach (95% CI)

N patients 256 166 134 60 3838

FistulasFistulas (%) - DigestiveDigestive 13 66 27 27 10 (0-20)10 (0-20)- PancreaticPancreatic 16 17 17 22 11 (2-22)Hemorrhage 14 88 16 13 13 (2-23)13 (2-23)Mortality 42 18 21 28 11 (2-22)11 (2-22)

Necrosectomy Retroper.

LaparoscopyLaparoscopy drainage lavagelavage laparotomy Approach (95% CI)

N patients 256 166 134 60 3838

FistulasFistulas (%) - DigestiveDigestive 13 66 27 27 10 (0-20)10 (0-20)- PancreaticPancreatic 16 17 17 22 11 (2-22)Hemorrhage 14 88 16 13 13 (2-23)13 (2-23)Mortality 42 18 21 28 11 (2-22)11 (2-22)

ConclusionsConclusions

1.1. Past pancreatitis is a poor indicator of CBDS.IOC is Past pancreatitis is a poor indicator of CBDS.IOC is indicated regardless of the risk of CBDS.indicated regardless of the risk of CBDS.

2.2. Prognostic systems can discriminate patients with Prognostic systems can discriminate patients with non severe ABP (Negative Predictive Value).non severe ABP (Negative Predictive Value).

3.3. Timing of open or laparoscopic biliary surgery Timing of open or laparoscopic biliary surgery depends on AP severity.depends on AP severity.

4.4. ES is NOT indicated in BENIGN ABPES is NOT indicated in BENIGN ABP..5.5. ES is indicated in case of Severe Cholangitis ES is indicated in case of Severe Cholangitis

associated with Severe ABP.associated with Severe ABP.6.6. CBD exploration is more efficient than ERC/ES. CBD exploration is more efficient than ERC/ES.

Performing ERC after LC+IOC rather than before LC Performing ERC after LC+IOC rather than before LC minimizes costs and morbidity.minimizes costs and morbidity.

7.7. The lThe laparoscopic approach for necrotic aparoscopic approach for necrotic collections is not a standard of carecollections is not a standard of care

Pancreatic pseudocysts

• Non surgical techniques– Percutaneous aspiration-drainage– Endoscopic transgastric drainage– Endoscopic transpapillary procedures

• Laparoscopic alternativesLaparoscopic alternatives *– Pancreatic cystogastrostomyPancreatic cystogastrostomy– Pancreatic cystojejunostomyPancreatic cystojejunostomy

* Cuschieri, Gagner, Meltzer, Mouiel, Park, Way.* Cuschieri, Gagner, Meltzer, Mouiel, Park, Way.

LAPAROSCOPIC INTERNAL DRAINAGE OF PSEUDOCYSTS

Petelin Transgastric

Handsewn

Cystogastrostomy

Litwin & Ross Stapled

Intraluminal

Cystogastrostomy

Cushieri Infracolic Cystojejunostomy

Palanivelu L. paracolic handsewn

Cystojejunostomy

Therapeutic laparoscopy of the pancreas

Park, A. Ann Surg 2002; 236(2):149-158

• 28 patients underwent laparoscopic pancreatic pseudocystectomy

a. pancreatic cyst gastrostomy via the lesser sac approach

b. minilaparoscopic pancreatic cyst gastrostomy

c. intragastric pancreatic cyst gastrostomy

d. pancreatic cyst jejunostomy

Therapeutic laparoscopy of the pancreas

• 25 patients underwent laparoscopic distal pancreatectomy

a. insulinoma

b. cystadenoma

c. chronic pancreatitis

d. simple cyst

4- Pancreatic trauma

Laparoscopic Distal Pancreatectomy for Blunt Injury to the Pancreas with

Splenic Preservation

• 10 yo handle bar injury

• CT –free fluid and distal transection of the pancreas

• Distal pancreatectomy with splenic preservation performed

• Reg diet POD 2

• D/C POD 3

Ferzli,G et al; Surg Endosc July2001

III-Palliative Laparoscopy for Unresectable Pancreatic

Cancer

Laparoscopic Gastro- and Hepaticojejunostomy

CASE-CONTROL STUDY

14 patients – open palliation

10 patients – laparoscopic palliation

4 patients – diagnostic laparoscopy

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

Results

OPEN

(n=14)

LAP

(n=14)MORBIDITY 43% 7%

MORTALITY 29%

0%

HOSPITAL STAY

21 days

9 daysp<0.06

p<0.05

p<0.05

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

Conclusion

Laparoscopic palliation can reduce the three major drawbacks of open bypass surgery-i.e., high morbidity, high mortality, and

long hospital stay.

Rothlin,M et al;Surg Endosc (1999) 13:1065-1069

SUMMARY

• Laparoscopy and laparoscopic ultrasound are sensitive and specific tools for determining resectability in patients with pancreatic cancer

• Laparoscopic techniques can be used for the treatment of benign and malignant pancreatic diseases and pancreatic trauma