TLPD improves overall quality of life, but not surgical complication rates

The last two decades have seen major advances in pancreatic cancer surgery. Operative outcomes for open pancreas resection have improved dramatically, with high-volume centers now reporting 1 to 2 percent mortality rates, compared with mortality rates approaching 25 percent in the 1960s.

Techniques for treating locally advanced cancers involving the portal and superior mesenteric veins have also improved. Vascular invasion is no longer always a surgical contraindication, making resection a possibility for an increasing number of patients. Although reports are mixed, patients undergoing pancreaticoduodenectomy (PD) with vascular resection and reconstruction seem to have outcomes relatively similar to those of patients undergoing PD alone.

Another important advance occurred with the introduction of laparoscopy into pancreatic surgery in the 1990s. First used as a diagnostic and staging tool to assess masses in the pancreas, tumor spread to surrounding organs and invasion of vascular structures, laparoscopy later extended to surgical treatment of benign disease and, more recently, malignant disease.

Although adoption of minimally invasive techniques in pancreatic surgery has been relatively slow compared with other surgical specialties, laparoscopy is now the gold standard for distal pancreatectomy. Some skepticism — and slower acceptance — remain relative to total laparoscopic PD (TLPD). This is due to the number of technically challenging anastomoses required and the high degree of skill and experience needed to perform them as well as a perceived lack of benefit over open approaches.

The Mayo Clinic experience

In 2010, a Mayo Clinic study published in Archives of Surgery (now JAMA Surgery) demonstrated the safety, technical feasibility and noninferiority of TLPD. In that series, 62 patients with benign or malignant disease underwent total laparoscopic pancreaticoduodenectomy; robotic assistance was used during reconstruction in eight patients.

KMarie Reid Lombardo, M.D., M.S., a hepatobiliary and pancreas surgeon at Mayo Clinic's campus in Rochester, Minnesota, notes that robotic surgery isn't a third option but rather laparoscopy with the benefits a robot provides.

"With the robot, vision is sharper and clearer, and the robotic arm can rotate in ways the wrist can't," she says. "Some in the community think the robot is oversold and overdone and that there is no uniform approach to its use. Others have found that it enables meticulous dissection and precision in suturing, especially when we are reconstructing the pancreatic duct. On the other hand, we have not found a lower leak rate with the robot or laparoscopic surgery in general."

In 2011, Mayo Clinic surgeons were the first to describe, in HPB, the technique and outcomes of a series of patients undergoing laparoscopic major venous resection and reconstruction. Reported outcomes were equivalent to open surgery, with no post-surgical or in-hospital mortality, but the authors strongly stressed the high degree of skill and experience needed to achieve optimum results.

Mayo studies have also shown the same oncological outcomes for open and laparoscopic surgery. In a 2012 article in The Cancer Journal, Mayo surgeons reported that minimally invasive pancreatic resection provides the same quality-of-life benefits seen with other types of laparoscopic surgery.

"With laparoscopic approaches, patients leave the hospital in three to four days as opposed to a week or more, and because they recover more quickly, they can start chemotherapy sooner, so the two go hand in hand. Furthermore, pain control is better, people return to work sooner — all the benefits are there," Dr. Reid Lombardo explains.

Little change in morbidity, patient eligibility

Despite technical advances and reduced mortality, the morbidity associated with pancreas resection has remained essentially unchanged, Dr. Reid Lombardo says.

"We haven't been able to resolve the frequency of pancreatic fistula," she explains. "The pancreas can be soft and is easily susceptible to leaks, despite different suturing techniques different tools for transection, placement of surgical drain(s) or no drain, so the leak rate can be as high as 20 percent."

Delayed gastric emptying, intra-abdominal abscess and abdominal hemorrhage are other potential complications. Also unchanged is the number of patients eligible for pancreatic surgery.

"While we have made great strides, we are still not able to treat the vast majority of patients with pancreatic cancer. The diagnosis comes when the tumor is too locally advanced or already metastasized. About 1,000 patients come to Mayo Clinic for assessment each year, and only 200 of them receive surgery. The rest undergo chemotherapy and radiation or chemotherapy alone, with an overall five-year survival of 5 to 6 percent. With surgery, survival is 20 percent at five years," Dr. Reid Lombardo says.

"While making great advances, surgery is not a cure, but it is an opportunity for a cure. It gives patients the chance to live several months to a year and sometimes longer; laparoscopic surgery may help improve quality of life during that time."

For more information

Kendrick ML, et al. Total laparoscopic pancreaticoduodenectomy: Feasibility and outcome in an early experience. Archives of Surgery. 2010;145:19.

Kendrick ML, et al. Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB. 2011;13:454.

Kendrick ML. Laparoscopic and robotic resection for pancreatic cancer. The Cancer Journal. 2012;18:571.