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      Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy


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          Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.

          The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index >35 kg/m 2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.

          The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.

          The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

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          Laparoscopic pylorus-preserving pancreatoduodenectomy.

          A case of chronic pancreatitis localized in the head of the pancreas with pancreas divisum was treated by laparoscopic pylorus-preserving pancreatoduodenectomy. The laparoscopic technique of resection and reconstruction with a gastrojejunostomy, hepaticojejunostomy, and pancreaticojejunostomy is described. The postoperative period was complicated by a jejunal ulcer and delayed gastric emptying necessitating a prolonged hospitalization and intravenous hyperalimentation. No fistulas occurred, a follow-up CT scan revealed no pancreatic abnormalities, and the patient was discharged in good condition on the 30th postoperative day. Although technically feasible, the laparoscopic Whipple procedure may not improve the postoperative outcome or shorten the postoperative recovery period.
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            Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours

            Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial.
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              Laparoscopic distal pancreatectomy is associated with significantly less overall morbidity compared to the open technique: a systematic review and meta-analysis.

              To compare laparoscopic distal pancreatectomy (LDP) versus open distal pancreatectomy (ODP) by using meta-analytical techniques. LDP is increasingly performed as an alternative approach for distal pancreatectomy in selected patients. Multiple studies have tried to assess the safety and efficacy of LDP compared with ODP. A systematic review of the literature was performed to identify studies comparing LDP and ODP. Intraoperative outcomes, postoperative recovery, oncologic safety, and postoperative complications were evaluated. Meta-analysis was performed using a random-effects model. Eighteen studies matched the selection criteria, including 1814 patients (43% laparoscopic, 57% open). LDP had lower blood loss by 355 mL (P < 0.001) and hospital length of stay by 4.0 days (P < 0.001). Overall complications were significantly lower in the laparoscopic group (33.9% vs 44.2%; odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.57-0.95), as was surgical site infection (2.9% vs 8.1%; OR = 0.45, 95% CI 0.24-0.82). There was no difference in operative time, margin positivity, incidence of postoperative pancreatic fistula, and mortality. LDP has lower blood loss and reduced length of hospital stay. There was a lower risk of overall postoperative complications and wound infection, without a substantial increase in the operative time. Although a thorough evaluation of oncological outcomes was not possible, the rate of margin positivity was comparable to the open technique. The improved complication profile of LDP, taken together with the lack of compromise of margin status, suggests that this technique is a reasonable approach in selected cancer patients.

                Author and article information

                J Vis Exp
                J Vis Exp
                Journal of Visualized Experiments : JoVE
                MyJove Corporation
                17 June 2018
                17 June 2018
                : 136
                : 56819
                1Department of Surgery, Cancer Center Amsterdam, Academic Medical Center
                2General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona
                3Department of Surgery, OLVG
                Author notes

                Correspondence to: Marc G Besselink at m.g.besselink@ 123456amc.uva.nl

                Copyright © 2018, Journal of Visualized Experiments

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0/

                Cancer Research

                cancer research,issue 136,pancreas,surgery,laparoscopy,minimally invasive,periampullary cancer,pancreatic cancer,pancreatic anastomosis


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