Laparoscopic distal pancreatectomy (interventional procedures consultation)

Laparoscopic distal pancreatectomy is the removal of the left part of the pancreas (an organ in the upper abdomen that is involved in digestion and produces insulin). The procedure is carried out through small incisions in the abdomen, using a fine telescope to see inside the body (also known as 'keyhole surgery').

The National Institute for Health and Clinical Excellence is examining laparoscopic distal pancreatectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about laparoscopic distal pancreatectomy .

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
  
• the identification of factual inaccuracies
  
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 24 October 2006
Target date for publication of guidance: January 2007

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of laparoscopic distal pancreatectomy appears adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance.

Laparoscopic distal pancreatectomy should only be performed in centres specialising in pancreatic surgery and with appropriate expertise in advanced laparoscopic techniques, and in the context of a multidisciplinary team, which should usually include a pancreatic surgeon, a gastroenterologist, an endocrinologist and a pathologist.

Pancreatic neuroendocrine tumours and cystic tumours may be benign or malignant. The most common type of pancreatic neuroendocrine tumour is insulinoma, which is usually benign. In this condition, the tumour produces too much insulin, resulting in symptoms associated with low blood sugar, such as weakness, loss of energy, dizziness and drowsiness.

Chronic pancreatitis refers to long-term inflammation of the pancreas, which eventually causes irreversible damage to the tissue. Pseudocysts may develop, which are collections of pancreatic fluid resulting from blocked pancreatic ducts. The main symptom of chronic pancreatitis is abdominal pain, which may be mild or severe. Other symptoms include jaundice, steatorrhoea (fatty stools) and weight loss. Destruction of the cells that produce insulin may lead to diabetes. There is also an increased risk of pancreatic cancer.

The main treatment for cystic and neuroendocrine tumours is surgery, although chemotherapy may also be used for malignant tumours. Small benign insulinomas can be removed by enucleation. Larger tumours in the body and tail of the pancreas or close to the pancreatic duct are usually removed by open distal pancreatectomy. Current treatments for chronic pancreatitis include medication such as enzyme supplements and analgesics, and avoiding alcohol consumption. In rare cases, surgery may be necessary.

The evidence of efficacy comes from one review that included 15 studies describing a total of 282 laparoscopic distal pancreatectomies and 87 enucleations, and one non-randomised controlled trial of 30 patients.

The review reported a mean hospital stay of 7.5 days. The non-randomised controlled trial reported a significantly shorter median postoperative hospital stay after laparoscopic distal pancreatectomy than after open surgery (5 days versus 8 days, respectively, p = 0.02). The non-randomised controlled trial also reported that patients who underwent laparoscopic surgery felt they had returned to normal activity after 3 weeks (median), compared with 6 weeks for patients who underwent open surgery (p = 0.03).

The review reported a tumour recurrence rate of 5.7% at a mean follow-up of 27 months. For more details, refer to the sources of evidence (see appendix).

The evidence on safety relates to one review that included 15 studies describing a total of 282 laparoscopic distal pancreatectomies and 87 enucleations.

The rate of conversion to open surgery was approximately 14% (range 0% to 40%). The mean rate of re-operation to treat complications was 8% (range 0% to 17%). The mean incidence of pancreatic fistula was 13%.

The review reported 30-day mortality as 0.5%. For more details, refer to the sources of evidence (see appendix).

The Specialist Advisers stated that potential adverse effects of the procedure include haemorrhage, pancreatic fistula, anastomotic leakage and inadequate resection margins.

It was noted that some of the evidence related to laparoscopic enucleation procedures rather than laparoscopic distal pancreatectomy.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

• 'Interventional procedure overview of laparoscopic distal pancreatectomy', May 2006.