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Inicio Cirugía Española (English Edition) Laparoscopic pancreaticoduodenectomy: May we illuminate some shadows?
Journal Information
Vol. 99. Issue 3.
Pages 249-250 (March 2021)
Vol. 99. Issue 3.
Pages 249-250 (March 2021)
Letter to the Editor
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Laparoscopic pancreaticoduodenectomy: May we illuminate some shadows?
Duodenopancreatectomía cefálica laparoscópica: ¿podemos iluminar algunas sombras?
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Miguel Ángel Suárez Muñoz
Corresponding author
masuarez59@gmail.com

Corresponding author.
, Jorge Francisco Roldán de la Rúa, Luis Carlos Hinojosa Arco, Yolanda Eslava Cea
Unidad de Cirugía Hepatobiliopancreática, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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Francisco Espin Alvarez, María Isabel García Domingo, Manel Cremades Pérez, Esteban Cugat Andorrá
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Dear Editor,

We have read the recent article by Espín Álvarez et al., “Highs and Lows in Laparoscopic Pancreaticoduodenectomy”.1 First of all, we would like to congratulate the authors, not only for the results presented, but for their thoughts on such a widely debated topic: the incorporation into clinical practice of such a demanding procedure as minimally invasive pancreaticoduodenectomy (PD).2

When faced with this challenge in our unit, the safety of our patients was paramount.3 Being aware of the Achilles’ heel involved in performing pancreatic anastomosis, we designed a strategy based on stages that allows us to take advantage of our laparoscopic experience in hepatic and supramesocolic surgery (major and posterior segment hepatectomy, gastrectomy, distal pancreatectomy, splenectomy, etc) for the first phase of PD (laparoscopic phase). Subsequently, the 3 anastomoses are carried out in open surgery through a supraumbilical midline minilaparotomy. With this hybrid surgery concept (laparoscopic/laparotomic),4 we have operated on our first 10 patients in 2019, whose median hospital stay was 6 days (5–10); there was only one case of readmission for grade C fistula (unpublished data) and no 90-day mortality. In the laparotomic phase, we always perform the pancreatic division and the release of the retroportal lamina for better control of the drainage veins from the head of the pancreas to the mesenteric-portal trunk. On many occasions, this leads to non-progression during laparoscopic dissection, requiring conversion, as happened to the authors with one of their patients.

From the results presented, it is striking that the median stay of the group that underwent open PD was almost double the hospital stay for laparoscopic PD (15 vs 8.5 days). Meanwhile, the incidence of complications was only slightly higher (without reaching statistical significance) in the group of patients with open surgery. As the authors well argue, this was probably related to the patient selection, as the patients in the open surgery group had greater technical complexity or comorbidities.

We believe that the possibilities of developing laparoscopic PD in our units should be based on previous experience in open pancreatic surgery, careful patient selection (as shown in recent consensus documents5,6), specific training programs for the procedure,7 and an implementation strategy in which hybrid PD, such as our approach, has a place on the learning curve.8 With this roadmap, perhaps we can illuminate and eliminate some of the shadows that still haunt us.

References
[1]
F. Espín Álvarez, M.I. García Domingo, M. Cremades Pérez, E. Herrero Fonollosa, J. Navinés López, J. Camps Lasa, et al.
Luces y sombras de la duodenopancreatectomía cefálica laparoscópica.
[2]
D. Fuks.
Minimally invasive pancreatoduodenectomy.
Br J Surg, 107 (2020), pp. 630-631
[3]
M.A. Suárez Muñoz.
Complicaciones y secuelas de la cirugía pancreática ¿Cómo intentamos prevenirlas?.
Cir Andal, 30 (2019), pp. 181-185
[4]
J.F. Roldán de la Rúa, L.C. Hinojosa Arco, N.S. Ávila García, F. Ramos Muñoz, N. Martos Rojas, Y. Eslava Cea, et al.
Duodenopancreatectomía cefálica mediante abordaje híbrido (laparoscópico/laparotómico).
Cir Esp, 97 (2019), pp. 6
[5]
B. Edwin, M.A. Sahakyan, M. Abu Hilal, M.B. Besselink, M. Braga, J.M. Fabre, et al.
Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference.
Surg Endosc, 31 (2017), pp. 2023-2041
[6]
H.J. Asbun, A.L. Moekotte, F.L. Vissers, F. Kunzler, F. Cipriani, A. Alseidi, et al.
The Miami international evidence-based guidelines on minimally invasive pancreas resection.
[7]
T. De Rooij, J. van Hilst, B. Topal, K. Bosscha, D.J. Brinkman, M.F. Gerhards, et al.
Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2).
Ann Surg, 269 (2019), pp. 344-350
[8]
H. Pham, C.B. Nahm, M. Hollands, T. Pang, E. Johnston, H. Pleass, et al.
Hybrid laparoscopic pancreaticoduodenectomy: an Australian experience and a proposed process for implementation.
ANZ J Surg, 90 (2020), pp. 1422-1427

Please cite this article as: Suárez Muñoz MÁ, Roldán de la Rúa JF, Hinojosa Arco LC, Eslava Cea Y. Duodenopancreatectomía cefálica laparoscópica: ¿podemos iluminar algunas sombras? Cir Esp. 2021;99:249–250.

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