Yunqiang Cai

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis

BackgroundLaparoscopic pancreaticoduodenectomy (LPD), an advanced minimally invasive technique, has demonstrated advantages to open pancreaticoduodenectomy (OPD). However, this complex procedure requires a relatively long training period to ensure technical proficiency. This study was therefore designed to analyze the learning curve for LPD.MethodsFrom October 2010 to September 2015, 63 standard pancreaticoduodenectomy procedures were to be performed laparoscopically by a single surgeon at the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 57 patients were included in the study. Data for all the patients, including preoperative, intraoperative, and postoperative variables, were prospectively collected and analyzed. The learning curve for LPD was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All of the variables among the learning curve phases were compared.ResultsBased on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–11), phase II represented the technical competence period (cases 12–38), and phase III was regarded as the challenging period (cases 39–57). The operative time, intraoperative blood loss, and postoperative ICU demand significantly decreased with the learning curve. More lymph nodes were collected after the initial learning period. There were no significant differences in terms of postoperative complications or the 30-day mortality among the three phases. More challenging cases were encountered in phase III.ConclusionsAccording to this study, the learning curve for LPD consisted of three phases. Conservatively, to attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience.

Solid pseudopapillary tumor of the pancreas in male patients: report of 16 cases.

AIM To investigate the clinical characteristics, surgical strategies and prognosis of solid pseudopapillary tumors (SPTs) of the pancreas in male patients. METHODS From July 2003 to March 2013, 116 patients were diagnosed with SPT of the pancreas in our institution. Of these patients, 16 were male. The patients were divided into two groups based on gender: female (group 1) and male (group 2). The groups were compared with regard to demographic characteristics, clinical presentations, surgical strategies, complications and follow-up outcomes. RESULTS Male patients were older than female patients (43.1 ± 12.3 years vs 33.1 ± 11.5 years, P = 0.04). Tumor size, location, and symptoms were comparable between the two groups. All patients, with the exception of one, underwent complete surgical resection. The patients were regularly followed up. The mean follow-up period was 58 mo. Two female patients (1.7%) developed tumor recurrence or metastases and required a second resection, and two female patients (1.7%) died during the follow-up period. CONCLUSION Male patients with SPT of the pancreas are older than female patients. There are no significant differences between male and female patients regarding surgical strategies and prognosis.

Biliary tract intraductal papillary mucinous neoplasm: Report of 19 cases

AIM To gain a better understanding of biliary tract intraductal papillary mucinous neoplasm (BT-IPMN). METHODS From January 2000 to December 2013, 19 cases of BT-IPMN were retrospectively identified from a total of 343 biliary tract tumors resected in our single institution. Demographic characteristics, clinical data, pathology, surgical strategies, and long-term follow-up were analyzed. RESULTS The mean age of the 19 BT-IPMN cases was 53.8 years (range: 25-74 years). The most common symptom was abdominal pain (15/19; 78.9%), followed by jaundice (7/19; 36.8%). Cholangitis was associated with most (16/19; 84.2%) of the BT-IPMN cases. Macroscopically visible mucin was detected in all 19 patients, based on original surgical reports. The most common abnormal preoperative imaging findings for BT-IPMN were bile duct dilation (19/19; 100%) and intraluminal masses (10/19; 52.6%). Thirteen (68.4%) cases involved the intrahepatic bile duct and hilum. We performed left hepatectomy in 11/19 (57.9%), right hepatectomy in 2/19 (10.5%), bile duct resection in 4/19 (21.1%), and pancreatoduodenectomy in 1/19 (5.3%) patients. One (5.3%) patient was biopsied and received a choledochojejunostomy because of multiple tumors involving the right extrahepatic and left intrahepatic bile ducts. Histology showed malignancy in 10/19 (52.6%) patients. The overall median survival was 68 mo. The benign cases showed a non-significant trend towards improved survival compared to malignant cases (68 mo vs 48 mo, P = 0.347). The patient without tumor resection died of liver failure 22 mo after palliative surgery. CONCLUSION BT-IPMN is a rare biliary entity. Complete resection of the tumor is associated with good survival, even in patients with malignant disease.

Laparoscopic splenectomy for splenic littoral cell angioma

AIM To establish the safety and feasibility of laparoscopic splenectomy (LS) for littoral cell angioma (LCA). METHODS From September 2003 to November 2013, 27 patients were diagnosed with LCA in our institution. These patients were divided into two groups based on operative procedure: LS (13 cases, Group 1) and open splenectomy (14 cases, Group 2). Data were collected retrospectively by chart review. Comparisons were performed between the two groups in terms of demographic characteristics (sex and age); operative outcomes (operative time, estimated blood loss, transfusion, and conversion); postoperative details (length of postoperative stay and complications); and follow-up outcome. RESULTS LS was successfully carried out in all patients except one in Group 1, who required conversion to hand-assisted LS because of perisplenic adhesions. The average operative time for patients in Group 1 was significantly shorter than that in Group 2 (127 ± 34 min vs 177 ± 25 min, P = 0.001). The average estimated blood loss in Group 1 was significantly lower than in Group 2 (62 ± 48 mL vs 138 ± 64 mL, P < 0.01). No patient in Group 1 required a blood transfusion, whereas one in Group 2 required a transfusion. Two patients in Group 1 and four in Group 2 suffered from postoperative complications. All the complications were cured by conservative therapy. There were no deaths in our series. All patients were followed up and no recurrence or abdominal metastasis were found. CONCLUSION LS for patients with LCA is safe and feasible, with preferable operative outcomes and long-term tumor-free survival.

Laparoscopic distal pancreatectomy for solid-pseudopapillary tumor of the pancreas.

Purpose: Solid-pseudopapillary tumor (SPT) of pancreas is a rare entity with a low malignant potential. We aimed to identify the safety and the feasibility of laparoscopic distal pancreatectomy for SPT. Methods: From May 2008 to August 2011, we performed 4 cases of laparoscopic, spleen-preserving, distal pancreatectomies for patients with SPT. We retrospectively collected the demographic characteristics, operative and postoperative details, and follow-up outcomes of the patients. Results: Three female patients and 1 male patient with SPT underwent laparoscopic, spleen-preserving, distal pancreatectomy. The average operating time was 200 minutes. The average blood loss was 90 mL. The postoperative course of these patients was uneventful. All patients were followed-up and no local recurrence or metastasis was found. Conclusions: Laparoscopic distal pancreatectomy for patients with SPT is safe and feasible, with preferable operative outcomes, long-term tumor-free survival, and high spleen-preserving rate.

Few Comments on “Laparoscopic Splenectomy: Perioperative Management, Surgical Technique, and Results”

Dear Sirs, We read with great interest the online first article in Journal of Gastrointestinal Surgery by Fisichella et al. entitled “Laparoscopic Splenectomy: Perioperative Management, Surgical Technique, and Results.” The authors presented the description of their preoperative evaluation, surgical technique, and postoperative management and results of laparoscopic splenectomy (LS)in their study. However, we discuss several concerns about their study. The authors stated that portal hypertension, ascites, and traumatic injuries to the spleen were the absolute contraindications to LS. Portal hypertension was indeed considered as a contraindication to LS in the clinical practice guidelines of the European Association for Endoscopic Surgery in 2008. However, due to development of the operative instruments and accumulating of operating experience, many studies reported that it was safe and feasible to perform LS in patients with portal hypertension. ,3 Laparoscopic splenectomy for splenic injury was also reported in several reports. ,5 The indications for the LS should be better defined. The authors reported that they successfully performed LS for three patients with platelet count less than 10,000/μL, without platelet transfusion.We have performed approximately 80 cases of LS for immune thrombocytopenia (ITP) patients with platelet count less than 10,000/μL. Only three patients in our series required conversion to open surgery. In our practice, the hemostasis of the cut edge could be achieved by using ultrasonic dissector or LigaSure vessel sealing system. However, more evidence is required to validate the safety and feasibility of performing LS for ITP patients with platelet count less than 10,000/μL. A hand port allows surgeons to recover the tactile sensation. The hands of surgeons can work as a retractor, which facilitate the mobilization of spleen. Furthermore, it enables surgeons to get a quick access to hemorrhage and facilitates the retrieval of spleen from the abdomen. Compared with laparoscopic splenectomy, hand-assistant laparoscopic splenectomy is associated with a shorter operating time, lower conversion, and less blood loss. It may be superior to laparoscopic splenectomy in setting of massive splenomegaly or those with adhesions from previous surgeries. In conclusion, we appreciate that Fisichella et al. shared their scrumptious experience in laparoscopic splenectomy. However, the indications for LS should be better defined. We also recommend that hand-assistant LS is superior to laparoscopic splenectomy in setting of complicated spleens, especially to the less experienced surgeons.