The quest for optimization of laparoscopic pancreaticoduodenectomy with pancreaticogastrostomy

Abstract

Background: Pancreatic reconstruction remains the Achilles heel of pancreaticoduodenectomy (PD), especially in minimally invasive surgery. We developed a novel 3D-laparoscopic pancreaticoduodenectomy (3D-LPD) procedure with umbrella-pancreaticogastrostomy (uPG) plus roux-en-y gastroenterostomy (RY-GE) reconstruction, and analysed its outcomes in a prospective non-randomized single-centre cohort study (NCT02671357). Methods: Between March 2014 and March 2017, we performed LPD in 102 consecutive patients. We optimized the LPD procedure in 3 stages and routinely placed a pancreatic stent to secure duct patency. In the 1ststage, we performed LPD as a copy of our standard open PD procedure with telescope-PG plus iso-peristaltic gastroenterostomy (n=21). In the 2ndstage we used a uPG reconstruction instead of telescope-PG (n=29), and in the final stage a uPG plus RY-GE reconstruction instead of the standard iso-peristaltic gastroenterostomy (n=52). Results: In the final-stage LPD clinical pancreatic fistula (cPOPF) occurred in 4%, haemorrhage (PPH) in 4%, and severe complications (TOSGS ≥3a) in 10%. None of the patients developed delayed gastric emptying (DGE). In the 1st- and 2nd-stage LPD the rates of cPOPF were 48% and 31% (p<0.001), PPH 33% and 14% (p=0.003), severe complications 57% and 31% (p<0.001), and DGE 5% and 38% (p<0.001), respectively. Median (range) LOS after final-stage LPD was 9 (3-70) days, as compared to 23 (11-56) days after 1st-stage and 22 (10-72) days after 2nd-stage LPD (p<0.001). Postoperative mortality throughout the 3 stages of LPD was 2%. A 52-year old male patient died due to cPOPF with haemorrhage on day 29 after 1st-stage LPD. An 81-year old female patient died on day 3 after the final-stage LPD due to cardiac arrest based on autopsy-proven cardiac amyloidosis. Conclusions: LPD with uPG plus RY-GE is associated with excellent clinical outcomes and no DGE. Further investigation is warranted before considering replacement of current reconstruction Methods in pancreaticoduodenectomy.