A Stauffer, John

Objectives. Surgery is the most effective treatment for pancreatic cancer. However, present literature varies on outcomes of curative pancreatic resection in the elderly. The objective of the study was to evaluate age as an independent risk factor for 90-day mortality and complications after pancreatic resection. Methods. Nine hundred twenty-nine consecutive patients underwent 934 pancreatic resections between March 1995 and July 2014 in a tertiary care center. Primary analyses focused on outcomes in terms of 90-day mortality and postoperative complications after pancreatic resection in these two age groups. Results. Even though patients aged 75 years or older had significantly more postoperative morbidities compared with the younger patient group, the age group was not associated with increased risk of 90-day mortality after pancreatic resection. Discussion. The study suggests that age alone should not preclude patients from undergoing curative pancreatic resection.

Laparoscopic pancreaticoduodenectomy (LPD) is one of the most complex procedures performed in laparoscopic abdominal surgery, and its practice is still limited to only a few selected centers. Surgeons need to be proficient in advanced laparoscopic techniques and have a thorough understanding of the advantages and disadvantages inherent to the laparoscopic approach. LPD can be divided into the following steps: division of the omentum and colon mobilization; division of the proximal bowel and gastroduodenal artery, and transection of the common bile duct; making a retropancreatic window; dissection of ligament of Treitz and division of the distal bowel; dissection of the uncinate process and superior mesenteric vessels; and reconstruction. In this article, we describe our conventional technique for LPD.

AbstractBackgroundLaparoscopic distal pancreatectomy (LDP) has been shown to have short‐term benefits over open distal pancreatectomy (ODP). Its application for pancreatic ductal adenocarcinoma (PDAC) remains controversial.MethodsFrom 1995 to 2014, 72 patients underwent distal pancreatectomy for PDAC at a single institution and were included in the study. Postoperative and long‐term outcomes of patients undergoing LDP (n = 44) or ODP (n = 28) were compared.ResultsLDP was associated with less blood loss (332 vs. 874 mL, p = 0.0012) and lower transfusion rates than ODP (18.2 vs. 50 %, p = 0.0495). Operative time was similar (254 vs. 266 min) for LDP and ODP; five patients (11.4 %) required conversion to ODP. Pancreatic fistulas (13.6 vs. 7.1 %) and major complications (13.6 vs. 25 %), were similar between LDP and ODP, respectively. Length of hospital stay (5.1 vs. 9.4 days, p = 0.0001) and time to initiate adjuvant therapy (69.4 vs. 95.6 days, p = 0.0441) was shorter for LDP than ODP. Tumor characteristics were similar but LDP was associated with more resected lymph nodes than ODP (25.9 vs. 12.7, p = 0.0001). One‐, three‐, and five‐year survival rates were similar between LDP (69, 41, and 41 %, respectively) and ODP (78, 44, and 32 %, respectively).ConclusionLDP is associated with less blood loss and need for blood transfusion, shorter hospital stay, and faster time to initiate adjuvant therapy than ODP for patients with PDAC. Postoperative outcomes and long‐term survival are similar between the two groups. LDP appears to be safe in the treatment of patients with PDAC.

Abstract Introduction: With an expanding population of patients requiring ventricular assist devices, it is inevitable that these patients will require noncardiac surgery. Ventricular assist devices provide mechanical support for a failing heart either as a bridge to transplant or now as a long-term support if transplant is not available, so-called destination therapy. These devices can add significant technical challenges to abdominal surgery, in that the power supply and drivelines crossing the abdomen can potentially be damaged. The use of preoperative or intraoperative imaging may aid in locating these devices and increase patient safety. Materials and Methods: We describe a laparoscopic cholecystectomy in two patients supported with HeartMate ® II (Thoratec Corp., Pleasanton, CA) left ventricular assist devices. Our use of fluoroscopic guidance in port placement is also described. A literature review was performed to assess the frequency of laparoscopic procedures performed on patients with similar ventricular assist devices and of complications associated with the device and other comorbidities. Results: Laparoscopic cholecystectomy was performed without significant intraoperative hemodynamic changes. The use of imaging, such as fluoroscopy, can identify the location of the ventricular assist device and its associated drive wires to assure they are not damaged intraoperatively. Conclusions: Laparoscopic cholecystectomy can be performed safely on patients with ventricular assist devices. Complications due to damage to the device can be avoided with the assistance of fluoroscopy to identify the implanted abdominal portions of the ventricular assist device. Each laparoscopic procedure performed on these patients presents the surgeon with unique obstacles in which careful operative planning and intraoperative monitoring are essential.

AbstractBackgroundMinimally invasive surgical techniques for pancreatic cancer are being applied with increasing frequency. With support of the literature, the location of the tumor within the pancreas is the factor which determines if these techniques can be safely used routinely by pancreatic surgeons.MethodsLiterature supporting minimally invasive techniques for all types of resections for pancreatic cancer was reviewed.ResultsMultiple meta‐analysis regarding laparoscopic distal pancreatectomy all support the routine use of laparoscopy for these lesions. There are several case series describing the safety and efficacious use of laparoscopy in pancreaticoduodenectomy, and results have been promising in these highly specialized centers.ConclusionsThe location of the tumor within the pancreas remains the most critical factor in the use of laparoscopy as the standard of care. Lesions in the body and tail, which are readily resected with a distal or subtotal pancreatectomy should be performed laparoscopically unless there is a clear reason why not to do so. Lesions in the head of the pancreas have been shown to be removed safely and effectively with laparoscopy. However, the technical skills necessary and the ability to teach these to trainees are the limiting factors to widespread use. Further series are necessary to assess if the laparoscopic approach to pancreaticoduodenectomy will play a similar role as the one it plays in the surgical treatment for distal lesions.