Minireview on laparoscopic hepatobiliary and pancreatic surgery.docx

Minireview on laparoscopic hepatobiliary and pancreatic surgery.docx

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Minireviewonlaparoscopichepatobiliaryandpancreaticsurgery

Minireviewonlaparoscopichepatobiliaryandpancreaticsurgery

ClaraTan-Tam and StephenWChung

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Abstract

Thefirstlaparoscopiccholecystectomywasperformedinthemid-1980s.Sincethen,laparoscopicsurgeryhascontinuedtogainprominenceinnumerousfields,andhas,insomefields,replacedopensurgeryasthepreferredoperativetechnique.Theroleoflaparoscopyinstagingcanceriscontroversial,withregardstogallbladdercarcinoma,pancreaticcarcinoma,hepatocellularcarcinomaandlivermetastasisfromcolorectalcarcinoma,laparoscopyinconjunctionwithintraoperativeultrasoundhaspreventednontherapeuticoperations,andfacilitatedtherapeuticoperations.Laparoscopiccholecystectomyisthepreferredoptioninthemanagementofgallbladderdisease.Meta-analysescomparinglaparoscopictoopendistalpancreatectomyshowthatlaparoscopicpancreatectomyissafeandefficaciousinthemanagementofbenignandmalignantdisease,andhavebetterpatientoutcomes.Apancreaticoduodenectomyisamorecomplexoperationandthelaparoscopictechniqueisnotfeasibleforthisoperationatthistime.Roboticassistedpancreaticoduodenectomyhasbeentriedwithlimitedsuccessatthistime,butwithcontinuingadvancementinthisfield,thisoperationwouldeventuallybefeasible.Liverresectionremainstobethebestmanagementforhepatocellularcarcinoma,cholangiocarcinomaandcolorectallivermetastases.Systematicreviewsandmeta-analyseshaveshownthatlaparoscopicliverresectionsresultinpatientswithequalorlessbloodlossandshorterhospitalstays,ascomparedtoopensurgery.Withimprovingequipmentandtechnique,andtheincorporationofroboticsurgery,minimallyinvasiveliverresectionoperativetimeswillimproveandbemoreefficacious.Withtheincorporationofroboticsurgeryintohepatobiliarysurgery,donorhepatectomieshavealsobeencompletedwithsuccess.Themanagementofbenignandmalignantdiseasewithminimallyinvasivehepatobiliaryandpancreaticsurgeryissafeandefficacious.

Keywords:

 Laparoscopic,Liverresection,Pancreatectomy,Cholecystectomy,Pancreaticoduodenectomy,Cancer,Tumour

Coretip:

 Thisminireviewpresentstheimportanceoflaparoscopyinfacilitatinglaparoscopichepatobiliaryandpancreaticsurgery,andtheefficacyandsafetyoflaparoscopichepatobiliaryandpancreaticsurgery.Laparoscopicsurgeryisthepreferredmanagementofbenignandmalignantdiseaseforselectedpatients.Theadvantagesincludeconfirmationofdiagnosis,preventionofnontherapeuticoperations,decreasedhospitalstayandbetterpost-operativefunctionandcosmeticoutcome.Meta-analysesdemonstratethatlaparoscopicliverresections,pancreatectomiesandcholecystectomiesareefficacious.Thereislessbloodloss;thehospitalstaysareshorterwithlaparoscopicsurgeries.Thereisnocompromisetotheoncologicalresectionmarginswhencomparedtoopensurgery.Laparoscopicsurgeryissafeandefficaciousinthemanagementofbenignandmalignanthepatobiliaryandpancreaticdiseases.

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LAPAROSCOPY

Pancreas

Pancreaticcancercarriesapoorprognosiswitha5-yearrelativesurvivalrateof5.8%（SEERStatFactSheets:

Pancreas）.Atleast80%ofpatientswithpancreaticcancerpresentwitheitherlocallyadvancedormetastaticdiseaseandarenotresectableatthetimeofdiagnosis[1].Completesurgicalresectionistheonlycurativetreatmentwithpotentialforlong-termsurvival[2].Accuratestagingisessentialintreatmentplanningandindeterminingappropriatemanagementofpatientswithpancreaticcancerbyselectingpatientswhocanbenefitfromsurgeryandidentifyingpatientswithnon-resectablediseasetoavoidnon-therapeuticlaparotomies[3].

Uptoonethirdofpatientswithhigh-qualitypreoperativeimagingwillhaveradiographicallyoccultdistantmetastaticorlocallyunresectablediseaseatthetimeofstaginglaparoscopy[2].Inpancreaticadenocarcinoma,laparoscopicstagingallowsfortheidentificationofsub-radiographicmetastaticdiseasein10%-15%ofpatientswithradiographicallyresectablecancer,andinapproximately30%ofpatientswithlocallyadvanceddisease[2].Staginglaparoscopyisassociatedwithdecreasedlengthofstay,reducedpostoperativepain,andahigherlikelihoodofreceivingsystemictherapycomparedtolaparotomywithoutsignificantlyincreasingoperativetime[2,4,5].

However,advancesinimagingtechnologyhavedecreasedtheyieldofstaginglaparoscopyovertime.Multiphase,multidetectorthin-slidecomputedtomography（CT）scansproducehigh-resolutionimagesprovidingdetailsaboutlocalvascularinvolvementanddistantmetastaticdisease[6].Endoscopicultrasound（EUS）isalsobeingincreasinglyusedtoimagethetumoranditsrelationshiptoadjacentstructuresandtoobtainbiopsiesofpancreaticlesionsandregionallymphnodes[6].AstudybyWhiteetal[7]evaluated1045patientsfromaprospectivedatabasewhounderwentstaginglaparoscopyforradiographicallyresectablepancreaticandperipancreatictumorsovera10yearperiodfrom1995to2005toexaminetheyieldofstaginglaparoscopy.Thestudyreportsthattheyieldoflaparoscopyhasdiminishedoverthe10yearperiodandexceeds10%onlyforpatientswithpancreaticadenocarcinoma[7].

Theuseofstaginglaparoscopyinpancreaticcancerremainscontroversial.Whetherstaginglaparoscopyshouldbeusedroutinelyoronlyinselectedcasesisamatterofdebate.Studiessuggestthatstaginglaparoscopyshouldbereservedforselectedcaseswheretheyieldislikelytojustifytheadditionalproceduralriskandcost.Studiesrecommendthatpatientswithtumourslargerthanthreecentimeters,tumoursintheneck,bodyortail,orpatientswithequivocalCTscanfindingsformetastaticdisease,maybenefitfromlaparoscopy[8,9].

Gallbladder

Gallbladdercarcinomaisararemalignancyandtheincidenceofintraorpost-operativediagnosisisbetween0.2%to2.8%.Duetoanincreaseinlaparoscopiccholecystectomies,incidentalfindingofgallbladdercancerhasalsoincreased[10].Thebestmanagementforgallbladdercarcinomaissurgicalresection:

aresectionwithmalignancynegativemargins（R0resection）.InaT3toT4gallbladdercarcinoma,anR0resectionwouldresultina26%5-yearsurvivalrate,ascomparedtoa9%survivalrateinalessthanR0resection[11].Ifgallbladdercarcinomaissuspectedonimaging,theroleoflaparoscopicstagingforgallbladdercarcinomahasbeenshowntobesensitiveindetectingunresectablediseaseanddiseasedlesions.Theevidencesupportsthatstaginglaparoscopydoesnotimpactonoverallsurvival,andpreventspatientswithunresectablediseasefromanontherapeuticlaparotomy[12].Theuseofalaparoscopicultrasoundasanadjuncttolaparoscopyfurtherincreasestheaccuracyandspecificityofdiagnosisandstaging[13].AretrospectivereviewcompletedbyFerrareseetal[10],furtherre-enforcestheroleofmeticulousperi-operativediagnosis,intraoperativestagingandcholecystectomyinpreventingunnecessarylaparotomies,andidentifythepatientswhowillbenefitfromaresection.

Liver

Thissectiondiscussestheimportanceoflaparoscopyandtheroleoflaparoscopicultrasoundinconfirmingthediagnosisandplanningtheliverresectionorablation.

Laparoscopyisparticularlyusefulincaseswhenresectabilityisuncertainpriortosurgery.Jarnaginetal[4]examinedthebenefitsofpreoperativelaparoscopyinpatientswithcolorectalmetastasis（CRM）,andidentifiedfivefactorsthatmaypredictthepresenceofoccultintrahepaticorextrahepaticdiseasethatmaymakepatientsunresectable.Thesefactorsarethepresenceofmorethanonelivertumor,positivenodestatusofprimarytumor,disease-freeintervaloflessthan1year,presenceoflivertumorthatislargerthan5cmandcarcinoembryonicantigen（CEA）levelgreaterthan200ng/mL.Ifanypatienthasmorethan2ofthesefactors,42%ofthetimewouldhaveoccultdiseaserenderingthemunresectable.

Accuratestagingofintrahepaticcholangiocarcinoma（IHC）isjustasimportant,ascompleteresectionoffersthebestlong-termsurvival.Patientswithlargelesions,positivenodesormultifocalIHCdonotbenefitfromresection[14].Anadjuncttostaginglaparoscopyisthelaparoscopicultrasound.Thelaparoscopicultrasoundissensitiveindetectingparenchymalliverlesions[15].Becauseofthis,theroutineuseoflaparoscopywithconcomitantlaparoscopicultrasoundcansavepatientsfromunnecessarylaparotomy[4,14].

Ifapatientwithhepatocellularcarcinoma（HCC）isnoteligibleforliverresection,thereareothermultimodalapproachestomanageHCCprimarilyorinconjunctionwithliverresectionorabridgetotransplantation:

localablationwithalcoholorradiofrequency,chemoembolization,andradioembolization[16].Thelaparoscopicultrasoundisusefulinthesecasesasitallowspreciseexaminationoftheselesionsandthesurroundingvessels,andfacilitatesultrasound-guidedablationofHCC.

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PANCREAS

Thissectionwillfocusontheroleoflaparoscopicdistalpancreatectomyandpancreaticoduodenectomy,andthealternativestomanagementofunresectablebiliaryandduodenalobstructivecancers.

Distalpancreatectomy

Reportofthefirstlaparoscopicdistalpancreatectomy（LDP）wasin1996[17,18].Subsequentstudieshavedemonstratedthatlaparoscopicdistalpancreatectomyisassafeasopendistalpancreatectomy[19].Itisnowincreasinglyperformedasthebetteralternateapproachfordistalpancreatectomyinselectedpatients.Twometa-analysesfurthersupportthatlaparoscopicdistalpancreatectomyisassociatedwithasignificantlylowerbloodlossandreducedle