Guidance
2 The procedure
2 The procedure
2.1 Indications
2.1.1 Laparoscopic pancreatectomy can be used in the treatment of a number of different conditions.
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Pancreatic neuroendocrine tumours (most commonly insulinoma) and cystic tumours (benign or malignant) are usually treated surgically. Small benign insulinomas can be removed by enucleation. Larger tumours in the body or tail of the pancreas or close to the pancreatic duct are conventionally removed by open distal pancreatectomy. Chemotherapy may also be used to treat some malignant tumours.
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Chronic pancreatitis refers to long-term inflammation of the pancreas, which eventually causes irreversible damage to the tissue. Treatment includes medication such as enzyme supplements and analgesics, and avoiding alcohol consumption. Surgery may occasionally be necessary, for patients with chronic pancreatitis complicated by pseudocyst formation.
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Adenocarcinoma seldom presents as a tumour in the tail of the pancreas but may occasionally be found on histological examination following resection of a space-occupying lesion.
2.2 Outline of the procedure
2.2.1 Laparoscopic pancreatectomy is performed under general anaesthesia. The abdomen is insufflated with inert gas and a number of small incisions are made to provide access for the laparoscope and surgical instruments. The pancreas is exposed, dissected to detach the body and tail from the adjacent retroperitoneal tissues, and transected. The resected tissue is usually enclosed in a bag and removed through a small incision in the umbilical area. The spleen may be preserved, or removed along with the pancreas. A drain is often left in the pancreatic bed and is removed a few days after surgery.
2.3 Efficacy
2.3.1 The evidence on 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.
2.3.2 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, p = 0.02). The non-randomised controlled trial also reported that patients who underwent laparoscopic surgery felt that they had returned to normal activity after 3 weeks (median), compared with 6 weeks for patients who underwent open surgery (p = 0.03).
2.3.3 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' section.
2.3.4 The Specialist Advisers stated that this is a novel procedure, with a lack of data on long-term follow-up.
2.4 Safety
2.4.1 The evidence on safety relates to one review that included 15 studies describing a total of 282 laparoscopic distal pancreatectomies and 87 enucleations.
2.4.2 The rate of conversion to open surgery was approximately 14% (range 0–40%). The mean rate of re-operation to treat complications was 8% (range 0–17%). The mean incidence of pancreatic fistula was 13%.
2.4.3 The review reported 30-day mortality as 0.5%. For more details, refer to the 'Sources of evidence' section.
2.4.4 The Specialist Advisers stated that potential adverse effects of the procedure include haemorrhage, pancreatic fistula, anastomotic leakage and inadequate resection margins.