The development and implementation of laparoscopic distal pancreatectomy in the United Kingdom: indications, results and learning curve of 570 patients

Abstract

Background: Laparoscopic distal pancreatectomy (LDP) is increasingly performed due to favourable perioperative outcomes. Nevertheless, data on the development of LDP on a nationwide level is lacking. This study investigated the development and learning curve of LDP in the United Kingdom (UK). Methods: A retrospective study of patients undergoing LDP in eleven tertiary referral centres in the UK between 2006 and 2016 was performed. Development of perioperative outcomes and indications was examined by differences in trends over time periods (2006–2009, 2010–2013, 2014–2016). For learning curve analysis the first 15 LDP cases performed of each centre were combined and compared to the subsequent cases. Results: In total, 570 LDP’s were included in the analysis. Median operating time was 240 min (interquartile [IQR] 182–300) with a median blood loss 200 mL (IQR 100–350). The rate of conversion to open distal pancreatectomy was 69 (12%). Most resected tumours were neuro-endocrine tumours (n = 152 [27%]), mucinous cystic neoplasm (n = 112 [20%]) and pancreatic ductal adenocarcinoma (n = 86 [15%]). Concomitant splenectomy was performed in 68% (n = 385) of the cases. Complications occurred in 49% (n = 276) of patients. The incidence of International Study Group on Pancreatic Fistula grade (POPF) B/C was 87 (15%). 26 (5%) patients required a reoperation. A low 90-day mortality of 1.4% (n = 8) occurred. Total length of hospital stay was 6 days (IQR 5 to 8 days). Over time, LDP gained popularity and was more frequently used for PDAC (7% [n = 5] vs 19% [n = 47]; P = 0.005) in the UK. Learning curve analysis showed improvement of estimated blood loss, rate of blood transfusions, complication rate (including POPF) and length of stay after the first 30 patients. Conclusion: Laparoscopic distal pancreatectomy is increasingly considered as a useful technique for lesions of the distal pancreas, included PDAC. Clear improvements of perioperative outcomes were found with expanding experience in LPD.