To investigate the feasibility and safety of total laparoscopic cardia function preserving gastrectomy for gastric carcinoma. Clinical data of 10 patients undergoing total laparoscopic cardia function preserving gastrectomy for gastric carcinoma from November 2020 to December 2021 were retrospectively collected. There were 7 males and 3 females. The mean age was (66.1±12.9) years (ranged from 38 to 86 years). All of the 10 patients were successfully performed total laparoscopic cardia function preserving gastrectomy without conversion to laparotomy. The time of digestive tract reconstruction was (24.8±3.3) min (20-30 min), and the intraoperative blood loss was (35±24) ml(20-100 ml). The time of postoperative exhaust was (2.5±0.9) days(2-3 d), the time of postoperative liquid diet was (2.25±0.87) days(2-3 d), postoperative hospital stay was (9.5±2.1) days(6-13 d). No surgical complications such as bleeding, anastomotic fistula or anastomotic stenosis occurred. Postoperative pathology showed that the proximal and distal margins of resected specimens were negative. Patients were followed up for 2 to 15 months, respectively. No death or tumor recurrence and metastasis occurred during the follow-up period. There were no symptoms of reflux after operation. Compared with total gastrectomy and proximal gastrectomy, total laparoscopic cardia function preserving gastrectomy can theoretically reduce the incidence of reflux esophagitis. We used manual suture method for digestive tract reconstruction, which can reduce the application of 2-3 stapling studs and reduce the cost of surgical materials. Compared with subtotal gastrectomy, total laparoscopic cardia function preserving gastrectomy has the advantages of more thorough lymph node dissection, with little residual gastric tissue; therefore, the blood supply is relatively better. The incidence of reflux esophagitis of total laparoscopic cardia function preserving gastrectomy for gastric cancer may was lower than total gastrectomy.为了探讨完全腹腔镜保留贲门胃癌根治术的可行性和治疗效果。回顾性收集2020年11月至2021年12月在浙江省人民医院行完全腹腔镜保留贲门胃癌根治术10例患者的临床资料。男7例，女3例；年龄（66.1±12.9）岁（38~86岁）。10例患者均成功实施腹腔镜保留贲门胃癌根治术，无中转开腹，消化道重建时间（24.8±3.3）min（20~30 min），术中出血量（35±24）ml（20~100 ml）。术后排气时间（2.5±0.9）d（2~3 d），术后进食流质饮食时间（2.25±0.87）d（2~3 d），术后住院时间（9.5±2.1）d（6~13 d）。术后未发生出血、吻合口瘘或吻合口狭窄等严重手术相关并发症。术后病理显示，切除标本近远端切缘均阴性。患者术后随访2~15个月，随访期间无死亡或肿瘤复发转移病例。术后无反流症状。与全胃切除和近端胃切除相比，保留贲门功能胃癌根治术理论上能降低反流性食管炎发生率。采用手工缝合法进行消化道重建，可以减少2~3个吻合器枪钉的应用，降低了手术材料费。与胃次全切除术相比，腹腔镜保留贲门胃癌根治术淋巴结清扫更彻底，胃残留组织很少、血供更好，降低了反流性食管炎的发生率。.
AIM To compare the safety and efficacy of robotic-assisted distal pancreatectomy (RADP) and laparoscopic distal pancreatectomy (LDP). METHODS A literature search of PubMed, EMBASE, and the Cochrane Library database up to June 30, 2015 was performed. The following key words were used: pancreas, distal pancreatectomy, pancreatic, laparoscopic, laparoscopy, robotic, and robotic-assisted. Fixed and random effects models were applied. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS Seven non-randomized controlled trials involving 568 patients met the inclusion criteria. Compared with LDP, RADP was associated with longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay. There was no significant difference in transfusion, conversion to open surgery, R0 resection rate, lymph nodes harvested, overall complications, severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and 30-day mortality between the two groups. CONCLUSION RADP is a safe and feasible alternative to LDP with regard to short-term outcomes. Further studies on the long-term outcomes of these surgical techniques are required. Core tip To date, there is no consensus on whether laparoscopic or robotic-assisted distal pancreatectomy is more beneficial to the patient. This is the first meta-analysis to compare laparoscopic and robotic-assisted distal pancreatectomy. We found that robotic-assisted distal pancreatectomy was associated with longer operating time, lower estimated blood loss, a higher spleen-preservation rate, and shorter hospital stay. There was no significant difference in transfusion, conversion to open surgery, overall complications, severe complications, pancreatic fistula, severe pancreatic fistula, ICU stay, total cost, and 30-day mortality between the two groups.
Abstract Background Postoperative pancreatic fistulas (POPFs) are prevalent and major postoperative complications of distal pancreatectomy (DP). There are numerous ways to manage the pancreatic stump. However, no single approach has been shown to be consistently superior. Moreover, the potential role of robotic systems in reducing POPFs has received little attention. Methods The clinical data of 119 patients who had consecutively received robotic distal pancreatectomy between January 2019 and December 2022 were retrospectively analyzed. Patients were divided into two groups according to the method of handling the pancreatic stump. The attributes of the patients and the variables during the perioperative period were compared. Results The analysis included 72 manual sutures and 47 stapler procedures. The manual suture group had a shorter operative time (removing installation time) than the stapler group (125.25 ± 63.04 min vs 153.30 ± 62.03 min, p = 0.019). Additionally, the manual suture group had lower estimated blood loss (50 mL vs 100 mL, p = 0.009) and a shorter postoperative hospital stay. There were no significant differences in the incidence of clinically relevant POPFs between the two groups (18.1% vs 23.4%, P > 0.05). No perioperative death occurred in either group. Conclusion The manual suturing technique was shown to have an incidence of POPFs similar to the stapler technique in robotic distal pancreatectomy and to be safe and feasible. Graphical Abstract
Objective: To summarize the incidence and characteristics of postoperative complications after laparoscopic pancreaticoduodenectomy(LPD), and to share our experience on management of complications. Methods: The clinical data of 320 LPD performed by a single team in Sir Run Run Shaw Hospital and Zhejiang Provincial People's Hospital between September 2012 and September 2017 were retrospectively analyzed, among which there were 196 males and 124 females with age of (60.2±11.6) years old.There were 306 patients who underwent standard LPD, and 14 patients who underwent extended LPD. The patients were divided into 2 groups of former 160 LPD and later 160 LPD according to the time order. By analyzing the differences of clinical outcomes between the two groups, especially focusing on the incidence of postoperative complications.The experience on management of complications was concluded. The prior surgical history of latter group was significantly higher than the former group(30.0%(48/160)vs. 18.8%(30/160), χ(2)=5.49, P=0.019), and the rest of baseline characteristics remained the comparable (P>0.05). For resectable lesions, LPD was performed by "No back" approach, following the principle of "From distal to cephalad, from ventral to dorsal, and from left to right" . As for the borderline resectable patients, LPD was performed by "Easy first" strategy. Student t test, χ(2) test or Fisher test was used to analyzed the data between the two groups respectively. Results: Of 320 LPD patients, 306 cases underwent standard LPD, 14 cases underwent LPD with resection of other organs.There were 278 LPD cases who followed "No back" approach, and 42 cases who followed "Easy first" strategy because of difficulty in creating the retro-pancreatic tunnel. And the overall morbidity was 32.2%(103/320) with reoperation rate of 5.3%(17/320). The perioperative mortality was 0.6%(2/320). The operation time of latter group was ((346.6±48.8)minutes), which was shorter than that of former group((358.0±54.4)minutes)(t=1.97, P=0.048). The blood loss of former and latter group remained comparable((207.9±135.8)ml vs.(189.6±121.4)ml, P=0.205). However, in subgroup analysis, the patients with blood loss less <200 ml of latter group decreased significantly from 59.4%(95/160) to 47.5%(76/160)(χ(2)=4.53, P=0.033). The overall morbidity of latter group was 28.8%(46/160), indicated a decrease from 35.6%(57/160) of former group without significant difference(P=0.188). Moreover, Grade A/B/C pancreatic fistula rate, Grade A/C bile leakage rate, Grade B/C postoperative hemorrhage rate of the later group tended to decrease, although they also didn't reach a significant difference. However, the abdominal infection rate decreased significantly(χ(2)=3.93, P=0.047). The length of hospital stay remained comparable(P=0.156). Conclusions: The most common complications after LPD were postoperative hemorrhage and pancreatic fistula. With specialized team and accumulated experience, the morbidity can decrease progressively by analyzing the leading cause and improving the technical skills.目的： 探讨腹腔镜胰十二指肠切除术(LPD)术后并发症的发生情况及防治经验。 方法： 回顾性分析2012年9月至2017年9月同一团队在浙江省人民医院和浙江大学医学院附属邵逸夫医院实施的320例LPD患者的临床资料，男性196例，女性124例，年龄(60.2±11.6)岁。行标准LPD 306例，扩大LPD 14例。按照手术时间的先后顺序，分为前期组(160例)和后期组(160例)。后期组患者术前有腹部手术史的比例为30.0%(48/160)，高于前期组的18.8%(30/160)(χ(2)＝5.49，P＝0.019)，两组其余一般资料的差异均无统计学意义(P值均>0.05)。对可切除病变，采用"No Back"策略行LPD，遵循"从足端到头端、从前到后、从左到右"的原则进行手术；对于门静脉前的胰后隧道无法贯通者，即交界可切除病变患者，采用"Easy First"策略行LPD。两组患者计量资料的组间比较采用Student t检验，计数资料的比较采用χ(2)检验或Fisher确切概率法。 结果： 320例患者中，306例行标准LPD，14例联合其他器官切除；278例采用"No Back"策略完成，42例因胰后隧道难以贯通而采用"Easy First"策略完成。后期组手术时间[(346.6±48.8)min]少于前期组[(358.0±54.4)min](t＝1.97，P＝0.048)。前期组和后期组的术中出血量分别为(207.9±135.8)ml和(189.6±121.4)ml，差异无统计学意义(P＝0.205)；但后期组术中出血量<200 ml的患者比例(47.5%，76/160)少于前期组(59.4%，95/160)(χ(2)＝4.53，P＝0.033)。后期组术后总体并发症发生率为28.8%(46/160)，较前期组的35.6%(57/160)有下降趋势，但差异无统计学意义(P＝0.188)。后期组腹腔感染率为1.9%(3/160)，低于前期组的6.3%(10/160)(χ(2)＝3.93，P＝0.047)。两组术后住院时间的差异亦无统计学意义(P＝0.156)。 结论： LPD术后常见并发症为胰瘘和出血。组建攻关团队，逐渐积累手术经验，严密监测，认真分析并发症发生的原因，进行技术改进，LPD术后并发症发生率可进一步降低。.
Laparoscopic pancreaticoduodenectomy (LPD) is safe and feasible in several centers. Herein an appropriate approach named “easy first” approach has been suggested to achieve the goal with better outcomes. It is useful in patients with borderline resectable pancreatic cancer (BRPC) in case to control the injury.
Background: Laparoscopic pancreaticoduodenectomy (LPD) may have potential minimal invasive advantages for selected patients in limited center. However, few studies analyzed the learning curve. This study aimed to analyze the learning curve of this procedure at a large volume set, and share our experience to surmount it. Methods: All prospectively maintained data of the consecutive LPDs was reviewed retrospectively. The procedures were performed by single surgeon. Patients were divided into four groups according to staged approach with different focuses: Group A (the first 30 patients), Group B (the second 30 patients), Group C (the third 30 patients), and Group D (the fourth and last 30 patients). And the changes of outcomes during different learning periods were analyzed. Results: Between September 2012 and July 2015, 120 patients underwent LPD. One hundred and eleven of them underwent totally LPD, and 9 patients underwent laparoscopic assisted pancreaticoduodenectomy (LAPD). The mean operative time (OT), mean blood loss and average length of hospital stay (LOS) was 359.8±57.6 min, 169.7±152.6 mL and 17.0±9.8 d respectively. A total of 42 (35%) patients developed morbidity with no mortality. The mean overall OT tended to decrease from 370.2±52.8 min in Group A to 342.0±73.1 min in Group D with the accumulating experience of the surgeon. Moreover, mean OT of pancreatojejunostomy and choledochojejunostomy also tended to decrease from 55.0±8.7, 39.8±11.7 min in Group A to 43.6±7.6, 27.7±11.8 min in Group D respectively. Meanwhile, the clinical outcomes tended to get better. Mean blood loss, morbidity and LOS decreased from 219.3±147.9 mL, 43.3%, 18.7±10.0 d in Group A to 140.1±73.6 mL, 23.3%, 14.4±6.2 d in Group C respectively except for Group D. Conclusions: Routine practice of the LPD procedure was feasible and safe. Gained experience can improve clinical outcomes in 30 to 60 operations by overcoming the learning curve.
Objective: To analyze the safety and effectiveness of minimal invasive surgery treating pancreatic neuroendocrine tumors (pNETs), and to summarize surgical characteristics and share experience. Methods: The clinical data of 80 pNETs treated by a single hospital from January 2015 to December 2019 were retrospectively analyzed. The patients were divided into laparoscopic group and robot group. And surgical procedures included pancreaticoduodenectomy (PD), distal pancreatectomy (DP), central pancreatectomy (CP), and tumor enucleation. Results: Of 80 patients, 76 cases (95%) underwent minimal invasive surgery and 4 cases (5%) changed to open surgery. There were 38 females, with median age of 54.4 (20-80) years and median BMI (17.0-38.0) kg/m(2). Among them, 24 patients (31.6%) underwent PD, 36 patients (47.4%) underwent DP, 8 patients (10.5%) underwent CP and 8 patients (10.5%) received tumor enucleation. The postoperative incidence of grade B/C pancreatic fistula was 35.5%, the incidence of abdominal infection was 10.5%, the postoperative bleeding was 7.9%, and the reoperation rate was 6.6%, without perioperative deaths. There was no significant difference in postoperative complications among different surgical methods, including postoperative pancreatic fistula (P=0.396), postoperative bleeding (P=0.297), postoperative abdominal infection (P=0.339) and reoperation (P=0.396). Conclusions: Surgical resection is an effective treatment for pNETs. pNETs are suitable for minimally invasive surgery with earlier stage and smaller tumor diameter. Minimally invasive surgery for pNETs is safe and feasible, and functional preserving surgery could take into consideration.目的： 分析微创手术治疗胰腺神经内分泌肿瘤（pNETs）的安全性和有效性，总结其手术治疗的特点和经验。 方法： 回顾性分析2015年1月至2019年12月浙江省人民医院收治的80例pNETs患者的临床资料。按手术路径分为腹腔镜组和机器人组，手术方式包括胰十二指肠切除术（MPD)、胰体尾切除术（MDP)、胰腺中段切除术（CP）和胰腺肿瘤剜除术（MPP）。 结果： 本组80例，其中成功完成微创手术76例（95%），中转开放4例（5%）。76例中女性38例（50%)，中位年龄54.4（20~80）岁，中位体质指数（BMI）24.0（17.0~38.0）kg/m(2)。腹腔镜手术67例（88.2%），机器人手术9例（11.8%）。手术方式如下：胰十二指肠切除术24例（31.6%），胰尾切除术36例（47.4%），胰腺中段切除术和胰腺肿瘤剜除术各8例（10.5%）。术后B/C级胰漏25例（35.5%），腹腔感染8例（10.5%），术后出血6例（7.9%），二次手术5例（6.6%）。无围手术期死亡。不同手术方式组术后并发症差异无统计学意义[术后胰漏（P=0.396）、出血（P=0.297）、腹腔感染（P=0.339）和二次手术（P=0.396）]。 结论： 手术切除是治疗pNETs的有效手段。多数pNETs分级较早，肿瘤直径小，适合微创手术；且微创手术治疗pNETs安全可行；早期手术更可能采用功能保留术式。.
Objective: To examine the clinical efficiency of laparoscopic gastroduodenostomy with BillrothⅠanastomosis with manual suture. Methods: The clinic data of 36 patients with gastric cancer who underwent laparoscopic gastroduodenostomy with Billroth Ⅰ anastomosis from November 2017 to September 2019 in Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People's Hospital were analyzed retrospectively.There were 22 males and 14 females, aged (64.3±9.3) years(range: 43 to 80 years), underwent complete laparoscopic gastroduodenostomy. The laparoscopic manual suture was used for Billroth Ⅰ anastomosis. Results: All the laparoscopic radical gastrectomy and manual suturing gastroduodenostomy were successfully performed. The operation time was (226.7±40.4) minutes (range: 180 to 320 minutes), including (24.8±7.1) minutes (range: 15 to 48 minutes) for gastroduodenostomy.There was (3.8±0.9) days (range: 2 to 6 days) for anal exhaust, (5.7±2.0) days (range: 3 to 13 days) for extubation of gastric tube, and (10.3±3.1) days (range: 7 to 19 days) for hospitalization. There was no death in perioperative period. Postoperative pathological report showed 3 cases of highly differentiated adenocarcinoma, 5 cases of moderately differentiated adenocarcinoma, 22 cases of poorly differentiated adenocarcinoma and 6 cases of signet ring cell carcinoma, including 27 cases in T1 stage and 9 cases in T2 stage. The number of lymph nodes harvested was 36.4±8.9 (range: 23 to 60). Lymph node metastasis was positive in 7 cases and negative in 29 cases. TNM stage included 24 cases in ⅠA stage, 8 cases in ⅠB stage and 4 cases in Ⅱ stage. After the operation, the upper digestive tract radiography showed that the anastomosis opening was unobstructed without complications such as anastomotic stenosis. Conclusion: Laparoscopic gastroduodenostomy with Billroth Ⅰ anastomosis with manual suture is safe and feasible, has a good short-term effect.目的： 探讨腹腔镜下人工缝合行胃十二指肠吻合术的可行性。 方法： 回顾性分析2017年11月至2019年9月于浙江省人民医院胃肠胰外科接受胃癌根治术+胃十二指肠吻合的36例胃癌患者的临床资料。男性22例，女性14例，年龄（64.3±9.3）岁（范围：43~80岁），于完全腹腔镜下行胃癌根治术，并采用腹腔镜人工缝合法进行胃十二指肠吻合。记录患者的手术时间、胃十二指肠吻合时间、术后肛门排气时间、拔除胃管时间等围手术期资料。 结果： 全部患者成功实施完全腹腔镜远端胃癌根治性切除+人工缝合法胃十二指肠吻合，手术时间（226.7±40.4）min（范围：180~320 min），其中胃十二指肠吻合时间（24.8±7.1）min（范围：15~48 min），术后肛门排气时间（3.8±0.9）d（范围：2~6 d），拔除胃管时间（5.7±2.0）d（范围：3~13 d），术后住院时间（10.3±3.1）d（范围：7~19 d）。围手术期无死亡病例。术后病理学检查示高分化腺癌3例，中分化腺癌5例，低分化腺癌22例，印戒细胞癌6例；T1期27例，T2期9例；淋巴结清扫数目（36.4±8.9）枚（范围：23~60枚），淋巴结转移阳性7例，阴性29例。TNM分期：ⅠA期24例，ⅠB期8例，Ⅱ期4例。术后复查上消化道造影，吻合口均通畅，无吻合口狭窄等并发症。 结论： 腹腔镜人工缝合法行胃十二指肠吻合术安全可行，具有较好的近期疗效。.
A growing body of evidence supports the use of laparoscopic pancreaticoduodenectomy (LPD) as an efficient and feasible surgical technique. However, few studies have investigated its applicability in pancreatic ductal adenocarcinoma (PDAC), and the long-term efficacy of LPD on PDAC remains unclear. This study aimed to compare the short- and long-term outcomes between LPD and open pancreaticoduodenectomy (OPD) for PDAC.The data of patients who had OPD or LPD for PDAC between January 2013 and September 2017 were retrieved. Their postoperative outcomes and survival were compared after propensity score matching.A total of 309 patients were included. After a 2:1 matching, 93 cases in the OPD group and 55 in the LPD group were identified. Delayed gastric emptying (DGE), particularly grade B/C DGE, occurred less frequently in the LPD group than in the OPD group (1.8% vs. 36.6%, P < 0.001; 1.8% vs. 22.6%, P = 0.001). The overall complication rates were significantly lower in the LPD group than in the OPD group (49.1% vs. 71.0%, P = 0.008), whereas the rates of major complications were similar (10.9% vs. 14.0%, P = 0.590). In addition, the median overall survival was comparable between the two groups (20.0 vs. 18.7 months, P = 0.293).LPD was found to be technically feasible with efficacy similar to OPD for patients with PDAC.
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