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The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve

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Abstract

Background

In our first experience, laparoscopic pancreatoduodenectomy (LPD) was associated with higher morbidity than open PD. Since, the surgical technique has been improved and LPD was avoided in some patients at very high risk of postoperative pancreatic fistula (POPF). We provide our most recent results.

Method

Between 2011 and 2018, 130 LPD were performed and divided into 3 consecutive periods based on CUSUM analysis and compared: first period (n = 43), second period (n = 43), and third period (n = 44).

Results

In the third period of this study, LPD was more frequently performed in women (46%, 39%, 59%, p = 0.21) on dilated Wirsung duct > 3 mm (40%, 44%, 57%; p = 0.54). Intraductal papillary mucinous neoplasm (IPMN) became the primary indication (12%, 39%, 34%; p = 0.037) compared to pancreatic adenocarcinoma (35%, 16%, 16%; p = 0.004). Malignant ampulloma re-increased during the third period (30%, 9%, 20%; p = 0.052) with the amelioration of surgical technique. The operative time increased during the second period and decreased during the third period (330, 345, 270; p < 0.001) with less blood loss (300, 200, 125; p < 0.001). All complications decreased, including POPF grades B/C (44%, 28%, 20%; p = 0.017), bleeding (28%, 21%, 14%; p = 0.26), Clavien-Dindo III–IV (40%, 33%, 16%; p = 0.013), re-interventions (19%, 14%, 9%; p = 0.43), and the hospital stay (26, 19, 18; p = 0.045). Less patients with similar-sized adenocarcinoma were operated during the second period (70%, 33%, 59%; p = 0.002) with more harvested lymph nodes in the third period (21,19, 25; p = 0.031) and higher R0 resection (70%, 79%, 84%; p = 0.5). On multivariate analysis the protective factors against POPF of grades B/C were pancreatic adenocarcinoma and invasive IPMN, BMI < 22.5 kg/m2, and patients operated in the third period.

Conclusion

This study showed that the outcome of LPD significantly improves with the learning curve and patient selection. For safe implementation and during the early learning period, LPD should be indicated in patients at lower risk of POPF.

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Acknowledgements

The authors would like to thank D. Roche for her editorial assistance and correction of the article.

Funding

No funding for this study.

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Authors and Affiliations

  1. Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France

    Safi Dokmak, Béatrice Aussilhou, Fadhel Samir Ftériche, Jeanne Dembinski & Alain Sauvanet

  2. Department of Anesthesiology and Intensive Care Medicine, Military Hospital of Tunis, Tunis, Tunisia

    Chihebeddine Romdhani

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  1. Safi Dokmak
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  2. Béatrice Aussilhou
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Correspondence to Safi Dokmak.

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Safi Dokmak, Béatrice Aussilhou, Fadhel Samir Ftériche, Jeanne Dembinski, Chihebeddine Romdhani, and Alain Sauvanet have no conflicts of interest or financial ties to disclose in relation to the results of the present study.

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Dokmak, S., Aussilhou, B., Ftériche, F.S. et al. The outcome of laparoscopic pancreatoduodenectomy is improved with patient selection and the learning curve. Surg Endosc 36, 2070–2080 (2022). https://doi.org/10.1007/s00464-021-08493-z

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